Proposal Form for The Members of the About My Area.co.uk

 

 

1. Name and Address details

Name/s including trading names: * Address : Postcode: Telephone: Contact E-mail: * Establishment Date Membership Number

2. Can you confirm that:

(i) your income for the past year & forthcoming year will not exceed £50,000? Yes No (ii) you have not or will not undertake work outside the United Kingdom or Republic of Ireland? Yes No (iii) disclaimers of liability are displayed on the web site? Yes No (iv) either you and/or your web site have procedures in force to immediately withdraw any materials? Yes No (v) either you and/or your web site have implemented (and maintain and update) procedures and/or programs designed to prevent or protect against unauthorised use or modification of or access to your computer and /or your website? Yes No (vi) any potentially contentious material is referred to solicitors for libel checking prior to publication? Yes No (vii) you agree that Your Database Ltd will be noted as an additional Insured Yes No If you have answered NO to any of the above, please give details on a separate sheet.

3. Please state:

Have any claims in respect of the risks to which this form relates ever been made againstthe business or any of the Principals? Yes No Are any of the Principals, Partners or Directors, AFTER FULL ENQUIRY, aware of any circumstances which might give rise to any such claim? Yes No Has any proposal in respect of the risk to which this form relates ever been declined or has any such insurance ever been cancelled or renewal been refused? Yes No If YES to any of the above, please give details on a separate sheet.

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.

Signature of Principal / Director/ Partner

Date:

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