Central Insurance Services Group Offshore Insurance Proposal form

Liability Insurance Proposal for Contractors in Oil Industry

Please make sure that before you fill out this form you
have read the information about Liabilities thoroughly.

| For your convenience, you can use the printable form |

Proposer:

Ltd Company Name:

If Company is not Ltd please supply the following details:

Full Trading Name:

Use this text box for the
full names of all
principals or partners:

Contact Details:

Full Address:

Post Code:

Home Telephone Number:

The Business for which this insurance is intended:

Business Description:
(as you would wish it
shown on policy)

In which geographical location do you normally work?

Nationality of Directors:

Date of company establishment:

Cover Required:

Employer's Liability:
Limit of indemnity:
£10,000,000 any one occurrence (onshore):
£5,000,000 any one occurrence (offshore):
Public Liability:
Limit of indemnity:
		any one occurence

Claims:

Have there been any incidents in the last 5 years which have, or could have, given rise to any claims:

If Yes, please give details below:

Year:

Description/Circumstances:

Amount Paid:

Amount Outstanding:

General:

Do you undertake any Manual Work:

If Yes, please provide details:

Does your work involve Offshore Trips:

If Yes, please provide details:

Max no. of days in any one year:

Describe fully the work undertaken:

Details of platforms/rigs on which work will be undertaken:

Names of owners/operators of such platforms/rigs:

Any working employees other than yourself:

If Yes, please clarify:

Details of wages paid:

Principal:

Other:

Has any insurer ever declined your proposal, refused to renew or cancelled your policy or imposed special items?:

if Yes, please give the name of the insurers, details of their action and their reasons for it:

Period of Insurance:

From:

To:

Payment method:

		Credit Card (Ex. AMEX)
		Cheque

IMPORTANT

Declaration:

You are reminded of the need to disclose any facts which the Company would take into account in the assessment and acceptance of this proposal. If you have any doubts as to whether certain facts are relevent please ask Central Group (for contact details see below). Failure to disclose all relevant facts may invalidate your policy or may result in your policy not operating fully.

By submitting this form, I declare that the information given in this Proposal Form is to the best of my knowledge and belief correct and complete in every detail and will be the basis of the contract between me and Lloyd's of London (The Company).


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