Brennan Insurances

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The Cleaning Industry

Disclosure: In completing this Proposal Form it is very important that you disclose fully & accurately all material facts, as failure to do so may result in insurance being void.
Material facts are those which may affect an Insurers assessment of the risk to be insured. If you have any doubt as to whether something is a material fact you should provide full details on this Proposal Form.

IMPORTANT : PLEASE ANSWER EACH OF THE FOLLOWING QUESTIONS IN FULL & WHERE APPLICABLE TICK THE APPROPRIATE BOX.

Your Details

Full name (including any trading names):

Address:

(Where the company is not limited we must have the names of all partners)

3	Tel No:	Fax No:
	Email:	Website:
4	Date Company established (if less than 12 months please provide full details of the relevant experience of directors/principals including name of previous companies worked for):

5	Give details of any trade associations or regulatory body that you are a member of:

Your Business

6	Business Description (give fullest possible description of all activities undertaken):

	(Note : cover will only apply to the business defined above)

Your Business Plans

7
		No of Employees	Own Employees wages (inc labour only subcontractors) €	Payments to Bona-Fide Subcontractors €	Turnover €
i)	Principals wages
ii)	Clerical wages
iii)	Window cleaning at ground level
iv)	Window cleaning by "pole system"
v)	Window cleaning above ground level but below 10M
vi)	Window cleaning or any other cleaning above 10m (but excluding abseiling/rope access & slings/cradle work
vii)	Absailing/rope access and slings cradle work
viii)	Domestic, shop and office cleaning (including carpet cleaning)
ix)	Supermarkets and shopping centres
x)	Factory, industrial and kitchen cleaning (but excluding specialist machinery cleaning)
xi)	Specialist machinery cleaning
xii)	Pressure washing/jetting
xiii)	Any other work? (e.g. stone, tank, boiler, duct or drain cleaning etc).
Please state the nature of the work and apply the appropriate figures in the boxes above.

	Totals

Your Insurance Requirements

Please state if you require quotes for more than one limit

a)	Public Liability/Products Liability incorporating:
	failure to perform (efficacy):
	deliberate acts
	treatment risks
	failure to secure premises
	incorrect destruction of goods
	damage to property being worked upon
	damage to third party whilst being operated

tick if required
YES	NO

Limit of Indemnity
€1.4m
€2.8m
€7m
Other	€

Employers Liability

€ 13m

Optional Extensions:

Loss/Consequential Loss of Keys

Financial Loss

Customer Goods at own premises

Fidelity Bonding

Misuse of Telephones

Your Heath & Safety Procedures

tick boxes

Do you have a written Health & Safety Policy as required by the 1988 Health & Safety at Work Act?

YES	NO

GENERAL QUESTIONS

10)	Employee Vetting
	Please detail what steps are carried out to vet the trustworthiness and honesty of employees

11)	Do you engage Bona-Fide Subcontractors?	YES	NO
	If YES do you check that they hold Public Liability Insurance with a limit of indemnity of not less than 1,000,000?	YES	NO
	(Definition: A bona-fide subcontractor is one who supplies their own equipment and operating staff & who should have their own Public/Products Liability Insurance with a limit of at least 1,000,000)
12)	Do you carry out any work which:
	a) Involves the use of heat away from your own premises?	YES	NO
	b) is on board ships, on off-shore installations, at airports, chemical or petrochemical works, nuclear installations or gas storage facilities?	YES	NO
	c) outside Republic of Ireland	YES	NO
	If you have answered YES to any of these questions please provide full details including turnover & wages estimates for these activities

13)	Loss of Keys Extension
	If you have opted for this extension please advise what systems you have in force for ensuring the security of the keys

14)	Do you carry out cleaning of carpets, soft furnishings, upholstery & the like?	YES	NO
	If YES, do you issue a written disclaimer of liability in respect of the treatment of such goods?	YES	NO
15)	Do you operate any recognised Quality Assurance Standards? e.g. ISOEN9002	YES	NO
	If YES, please state what the standard is

YOUR BUSINESS HISTORY & CLAIMS EXPERIENCE

16)

Have you or any director or partner ever had any claim made against you in the last 5 years, (whether insured or not) in respect of the insurance for which you are now proposing?

YES

If YES, please provide the following details, including the present position on any claims outstanding against you:

YEARS	Brief Details & type of claim	Amount Paid	Amount Outstanding
/
/
/
/
/

17)	Has any insurer ever declined to insure you, cancelled or refused to renew your insurance	YES	NO
	If YES, please provide full details

18)	Have you or any director or partner ever: been prosecuted under the Health & Safety at Work Act 1989?	YES	NO
	been convicted of or charged (but not yet tried) with a criminal offence other than a motoring offence? been concerned with any business which has been wound up, liquidated, dissolved or ceased to trade?
	If YES to the above please provide full details

19)	Name of Last Insurer
	Policy Number(s)
	Expiry Date of Current Policy
	Expiring Premium

IMPORTANT

DISCLOSURE : Notice to be included

NAME:

POSITION:

SIGNED:

DATE:

Email Address -

This email address will be used for correspondence regarding this On-Line form and for no other purpose.

I have read and agree to Brennan Insurances Terms and conditions.

YES

Click here to download our Terms of Business document.