| Contact Name |
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| Name of Insured individual, company or association |
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| E-mail |
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| Proposer Address & Postcode |
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| Contact Number |
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| Type of display |
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| Name of Event |
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| Venue of the display/event |
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| Postcode of event |
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| Date of Event |
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| Date cover required from |
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| Date cover required to |
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| Estimated maximum attendance at event |
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| Who is releasing the fireworks? |
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| Public Liability Indemnity Limit |
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| Employers Liability Cover |
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| Number of employees / volunteers |
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| Are any charges made for public entry or parking |
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| Estimated turnover/ revenue for paid entry displays |
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| Please give a detailed description of the activities taking place at the event including the use of any outside contractors and whether there will be any stall holders at the event |
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| Are there any dangerous or hazardous activities taking place at the event? |
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| Please tick any hazardous activities taking place at the event |
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| If 'Other' please state type |
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| Do all independent outside contractors have their own liability insurance? |
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| Will you be using the services of a bona-fide insured security or stewarding company? |
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| Please advise the number of stewards that will be in attendance at the event |
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| Will staging and seating be erected, and if so will this be carried out by suitably qualified professionals with their own insurance? |
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| Will alcohol be sold or supplied during the event? |
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| Is the event organised in accordance with The Department of Trade & Industry Firework Display Regulations? (*) |
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| Will there be first aid provisions at the event? |
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| Has the advice of the police and/or fire and local authorities been sought and if required their permission been granted and will either be present at the event? |
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| Do written contracts of hire exist between yourself and the venue? |
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Whilst organising or participating in an event, have you, any official, commitee member or co-organiser: |
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| Had any insurance declined or cancelled or special terms imposed? |
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| Been convicted or charged but not yet tried for any criminal offence other than a driving offence? |
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| Sustained any loss or damage or liability during the last 5 years, whether insured or not? |
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| Please provide the details of all claims or incidents whether insured or otherwise that have occurred in the last 5 years |
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| Policy Conditions (*) |
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| How did you hear about us? |
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| Help us avoid Spam. Enter the numbers shown |
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