Application form liabilty insurance

Component 1: Insurance

Please fill in for which insurance you want to receive quotations.

1. I would like to receive quotes for the following insurance policies: *

General liability insurance
Intellectual property insurance
Director's liability insurance
Business travel insurance

Component 2: Company information

Please fill in the general information of your company.

2. Company name

3. Trading name (if different)

4. Corporate address

5. Postal code

6. Chamber of commerce number (KvK)

7. Website

Component 3: General Liability

If you want a quotation for general liability, please answer the questions 8 untill 33

8. Locations (if other than the above)

9. Names companies to be insured

10. (Please explain relationship)

11. Please describe your activities as a (group of) company (companies), per insured entity (hoedanigheid)

12. Turnover past financial year (in €)

13. Turnover current financial year - estimated (in €)

14. Turnover next financial year - expected (in €)

15. Total number of employees

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

17. Sales and marketing (in %)

18. Laboratory Workers (in %)

19. Manual workers (in %)

20. Other - please describe (in %)

21. Total estimated wage roll (in €)

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

Yes
No

23. If yes: please upload your RI&E.

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

Yes
No

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

Yes
No

26. Does the applicant operate an inpatient facility?

Yes
No

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

Yes
No

28. Is there a Clinical Trial planned in this or next year?

Yes
No

29. List new products expected to be introduced.

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

31. Do you have any historic losses and/or circumstances that can lead to a loss?

Yes
No

32. If yes, please describe

33. 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.

Component 4: Intellectual property

If you already answered the questions for a general liability insurance (component 2), then you don't have to answer question 34 anymore. If you only want a quotation for intellectual property, please answer question 34.

34. What is your (expected) turnover this year (in €)?

Component 5: Director's liability

If you want a quotation for director's liability, please answer the questions 35 untill 40

35. Is the policyholder legally domiciled in the Netherlands?

36. Was the policyholder established less than two years ago?

37. Is the projected (consolidated) revenue for the next two fiscal years less than €2.5 million?

Yes
No

38. Does the policyholder have positive (consolidated) equity?

Yes
No

39. Does the policyholder have sufficient money for its obligations over the next 12 months?

Yes
No

40. Is the policyholder a financial institution (established for the purpose of a one-time event) and active in: real estate, high-tech, biotech, renewable energy, and software development?

Yes
No

Component 6: Business travel insurance

If you want a quotation for a business travel insurance, please answer question 41

41. How many days a year are spent on business travel?

Component 7: Contactperson

42. Name

43. Position in company

44. E-mail

45. Telephone number

46. 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.

47. Agreement *

I agree

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