Street Party Insurance Proposal Form

1. General Information

Are you an Insurance Broker or Direct Client Insurance Broker
Direct Client

Please state the name of the Street Party Organisers to be insured (or residents of street name)

Please provide an address for the insured for the Street Party Organisers

Contact Name

Contact Telephone

Contact Email

Has the event been held before? Yes
No

If yes how many times?

Has the event ever suffered a loss of any kind? Yes
No

If Yes please provide details.

Please state the location of the Street Party

When does your event start (time and date)?

When does your event finish (time and date)?

When will you begin setting up your event at the venue (time and date)?

When will you complete breaking down your event and leave the venue (time and date)?

2. Liability Insurance

Please state the required value for Public Liability Insurance (or values for multiple quotes) for example £5m?

Please state the maximum number of people attending

A. Have you ot the organisers ever sustained a Cancellation, Property or Liability loss at an event? Yes
No

B. Have you or the organisers ever had any insurance declined or special terms imposed (on event style insurance only) Yes
No

C. Have you or the organisers ever been convicted (or charged but not tried) of any criminal offence involving dishonesty of any kind? Yes
No

D. Will Adequate First Aid be provided? Yes
No

E. Has the permission of the local authority been sought and granted, if required? Yes
No

F. Has the advice of the local police and/or fire authority been sought, if required? Yes
No

G. Will either be present at the staging of the event? Yes
No

H. Are there any temporary structures? Yes
No

I. Will staging and seating be erected? Yes
No

J. Will this be carried out by suitably qualified professionals with their own insurance (PL= £5m)? Yes
No

Please confirm all of the following:

The road will be closed according to your highway authority requirements Yes
No

You have permission from the local governing bodies to close the road, if required Yes
No

You will have temporary traffic calming measures in place Yes
No

Any and all third parties and sub-contractors including bouncy castles and street performers will have their own public liability insurance before attending my event and have shown me a copy of their schedule of insurance. Yes
No

3. Final Confirmation

I declare that I have never been

1. Bankrupt
2. Disqualified from being a Company Director
3. Involved as an owner, director, or partner with any company that went into receivership, administration, or liquidation
4. Convicted (or charged but not tried) of any criminal offence involving dishonesty of any kind
5. Organising or attending an event where you have suffered a loss

I declare that I have never been a. Bankrupt b. Disqualified from being a Company Director c. Involved as an owner, director, or partner with any company that went into receivership, administration, or liquidation d. Convicted (or charged but not tried) Yes
No

If you have selected no please give details

Declaration

Important Notice

Please note that failure to disclose all material facts (that is those facts an insurer would likely to influence the acceptance or assessment of this proposal) may invalidate the Insurance. If you are in any doubt whether a fact is material you should disclose it. You are advised to keep a record (including copies of letters) of all information supplied to the Insurer for the purpose of entering into the contract of insurance. A copy of the completed proposal form is available on request for a period of 3 months after it’s completion.

Declaration

I / We declare that the particulars and statements given in this Proposal and the information provided are to the best of my/our knowledge and belief complete and true, and I am / We are willing to accept the Certificate of Insurance issued by Worldwide Hole ’N One Ltd on behalf of certain Lloyd’s Underwriters including its terms, conditions, and exclusions.

By ticking this box you agree to the above statements

Name

Position