Application form liabilty insurance

Company information

1. Name of applicant

2. Trading name (if different)

3. Corporate address

4. Postal code

5. Mailing address

6. Postcode

7. Chamber of commerce number (KvK)

8. Locations (if other than the above)

9. All named insureds

10. (Please explain relationship)

11. Please describe your Insured activities, per insured entity (hoedanigheid)

Requested Coverage and sum insured

12. Public liability (in €)

13. Pure financial loss (in €)

Financial information

Please provide the following information for the past, current and future financial years:

14. Past financial year (in €)

15. Current financial year (in €)

16. Next year - estimation (in €)

17. Employees (number)

Employees division

Enter the ratio of your employees below:

18. Clerical / Managerial staff not involved in manual work %

19. Sales and marketing (in %)

20. Laboratory Workers (in %)

21. Manual workers (in %)

22. Other - please describe (in %)

23. Total estimated wage roll (in €)

24. Was a Risk Inventarisation and Evaluation (RI&E) survey performed? If yes, please attach report.

25. Do any of the applicant’s employees provide direct patient care?

Yes
No

26. Do they carry their own individual medical professional liability coverage?

Yes
No

27. Does the applicant operate an inpatient facility?

Yes
No

28. Does the applicant or its employees have a financial interest in the products of the applicants clients?

Yes
No

29. Sponsored Clinical Trials (or planned/projected)

30. Product

31. Number of new subjects over the next policy period

32. Indications

33. Country

34. Please attach approved protocols and informed consent documents for active clinical trials.

35. List new products expected to be introduced.

36. List any discontinued products. (please indicate reason(s)

This application form and all materials submitted with it will be held in confidence. For further information about CNA's policies and practices with regard to the privacy and confidentiality of information provided by you to us, please see our Privacy Statement at www.cnaeurope.com or contact our Company Secretary at the address listed below. Completing and signing this Proposal form does not bind coverage. Coverage will not be bound, nor will a policy be issued until the applicant signifies acceptance of the company's premium quotation.

Historic loss

37. Policy period

38. Insurer

39. Number of claims

40. Total incurred

41. Have any known occurrence(s) not yet been reported?

Yes
No

42. Please enclose any documents, lists or explanations, as required, in response to various questions throughout the body if this insurance proposal. Please also provide copies of the following: Marketing or advertising brochures or descriptive mater.

43. Signature in full

44. Name (Please print.)

45. Position in company (Please print.)

46. E-mail

47. Date

Declaration

I/we declare that, after full enquiry, the contents of this proposal are true and that I/we have not misstated, omitted or suppressed any material fact or information. I/we agree that this proposal together with any other information supplied by me/us shall form the basis of any contract of insurance which may be effected. If there is any material alteration to the facts and information which I/we have provided or any new material matter arises before the completion of the contract of Insurance, I/we undertake to inform Underwriters.

All questions must be answered and the application must be signed and dated.

48. Agreement *

I agree

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