Central Group

Tel: 01224 656656
Fax: 01224 656657
Email: oil@central-group.com
 

Central Group
7-17 Albert Street
Aberdeen AB25 1XX

LIABILITY INSURANCE PROPOSAL FOR CONTRACTORS IN OIL INDUSTRY

Name of Proposer
If not a Limited Company show the full names (including forenames) of all principals or partners and the full trading name
   Home Telephone Number
  Full Address including Postcode

The Business for which this insurance is required
Give a description of the business as you would wish us to describe it in the Policy
   Please state nationality of directors and date of establishment of company

Cover Required
Employers Liability   Public Liability
Limit of Indemnity
£10,000,000 any one occurrence (onshore)
£5,000,000 any one occurrence (offshore)
  Limit of Indemnity
£2,000,000 any one occurrence
£5,000,000 any one occurrence

Claims
Have there been any incidents in the last 5 years which have, or could have, given rise to any claims?  
YES NO

If YES please give details below:

General
Do you undertake any MANUAL work?  
YES NO

If YES please provide specific details

Does your work involve OFFSHORE TRIPS?  
YES NO

If YES please provide details of the maximum number of days spent Offshore in any one year and describe FULLY the work undertaken

In which geographical location do you normally work?

Please provide details of platforms / rigs on which work will be undertaken together with owners / operators of such platforms / rigs

Other than yourself do you have any working employees?  
YES NO

If YES please clarify

Please provide details of wages paid
Principle  
 
Other  

Has any insurer ever declined your Proposal, refused to renew or cancelled your policy or imposed special items?  
YES NO

If YES please provide specific details

PERIOD OF INSURANCE
No insurance is in force until this Proposal has been accepted by the Company
From  
 
To  

PAYMENT METHOD
Credit Card (Ex. AMEX)
Cheque

DECLARATION Very Important

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 relevant please ask Central Group. Failure to disclose all relevant facts may invalidate your Policy or may result in your Policy not operating fully.

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).

Signed..............................................................         Date..............................................................