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    All questions marked with * are mandatory

    Your name*

    Name of insured*

    (Please enter the full name(s) and any trading names as they should appear on policy documents)

    What is the insured’s trading type?*

    If ‘Other’
    Provide details below

    Your address*

    Your postcode*

    Email address*

    Contact number*

    You are a:*

    If 'Other
    Specify below

    Have you ever suffered a loss (whether insured or not) in respect of any similar events?*

    If 'Yes'
    Provide details

    Event name*

    Start date of event*

    Finish date of event*

    Set up start date*

    Take down/dismantle end date*

    Name of venue*

    Venue address*

    Venue postcode*

    Maximum attendance throughout entire duration of event*

    Have all the licences, visas, permits been obtained and are all contractual arrangements in writing for the event?*

    If 'No'
    Provide details

    Is public liability cover required?*

    If 'Yes'
    Choose limit of indemnity

    Have you undertaken a risk assessment of the fireworks event? You may be asked to produce this*

    Do you have a written health and safety policy that all contractors/exhibitors are made aware of and required to comply with?*

    Who is responsible for the firing of the fireworks?*

    If 'Third party supplier'
    Complete questions A, B, C & D.

    A) If the answer to the question above is 'Third Party Supplier' will you check to ensure that such independent suppliers have their own Public Liability insurance with a Limit of Indemnity at least equal to that which you have requested and check that their insurance will be current for the entirety of your event? If the answer is 'No' you must inform us immediately.

    B) Name of Fireworks Company

    C) Do they have their own public liability insurance?

    D) What limit of indemnity do they have?

    Will there be a bonfire at the event?*

    If 'Yes'Who is responsible for erecting & clearing up the bonfire before and after the event?

    Is employers liability cover required?*

    If 'Yes'
    Number of paid employees and unpaid volunteers & assistants

    If employers liability cover is not required, please enter '0' below

    Company ERN Number (if applicable)

    Do any employees/volunteers carry out work at height in excess of 5m or depth of 2m?

    Do any employees/volunteers carry out work involving the application of heat, other than the preparation of food and drink?

    Is event equipment cover required?*

    If 'Yes'
    Event equipment cover sum to be insured

    Is cancellation cover required?*

    If 'Yes'Cancellation cover - total costs and expenses of the event

    Cancellation cover - total estimated gross revenue of the event

    (Please include total income generated from the event, not just profit)

    Has the event been held before?

    (Please note if this is a first time event then you can only insure for 'Pre-contracted gross revenue')

    Which cancellation cover type is required?

    Is non-appearance cover required?

    If ‘Yes’
    Please could you confirm:

    - Name/s of individual/s you require cover for?
    - D.O.B of all individual/s you require cover for?
    - What is their role in the event?
    - Is their attendance crucial to event going ahead?
    - Are they being paid to attend the event and if so how much is their fee?

    Is cancellation through terrorism cover required?

    Is cancellation through civil commotion cover required?

    Is cancellation through computer system failure required?

    Are you aware of any matter, fact, circumstance or incident existing or threatened that could possibly affect the Event(s) to be insured which might result in a loss under this insurance?

    If 'Yes'
    Please supply full details

    Do all independent outside contractors and stallholders hold their own liability insurance?*

    Do you confirm that no official, committee member, you or co-organiser:*

    - Has sustained any loss for damage or liability during the last 5 years, whether insured or not
    - Has had any insurance declined, cancelled, refused or had special terms imposed
    - Has been convicted of or charged (but not yet tried) or been given an official police caution in respect of any criminal offence other than a motoring offence
    - Has been declared bankrupt, insolvent or gone into liquidation
    - Has been the subject of a County Court Judgement, an Individual Voluntary Arrangement, a Company Voluntary Arrangement or a Sheriff Court Decree
    - Has been disqualified from being a company director
    - Has been prosecuted or have prosecutions pending under the Health & Safety at Work Act or any other statute or regulation
    - Has been censured by any Regulatory or trade body or any action taken against the company by the office of fair trading, consumer groups or the alike

    If 'No'
    Provide details

    Notes and additional information

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