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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

1 Full name (including any trading names):
*
2 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:
ofailure to perform (efficacy):
odeliberate acts
otreatment risks
ofailure to secure premises
oincorrect destruction of goods
odamage to property being worked upon
odamage to third party whilst being operated
tick if required
YESNO
Limit of Indemnity
1.4m
2.8m
7m
Other

b) 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
9 a) Do you have a written Health & Safety Policy as required by the 1988 Health & Safety at Work Act?
YESNO
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 NO
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 NO
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