Association Online Proposal

Insurance Date, Name and Address

Date from which I wish to be insured

Title (Mr/Mrs/Ms..)

First Name(s)

Surname

Address Line 1

Address Line 2

Town or District

City or County

Postcode

Country

Telephone

Insurance Declarations

1) I confirm that I maintain client’s records including a signed and dated consultation and consent form or contract and retain them for at least 5 years. (If you have not done this in the past or you are just starting in business please tick the box to confirm that you will do this).

2) I have never been subject to a disciplinary hearing or suspended from any Professional Organisation.

3) If you have held insurance for your business in the last 12 months please complete the following:

Insurer

Limit of Indemnity

Expiry date of the policy

4) I have never had any claims or suits for negligence, errors or omissions been made against me and I am not aware of any circumstances which may result in any such claims being made against me.

5) No Insurer has ever cancelled, declined refused to renew or accepted on special terms my professional insurance.

6) I have never been convicted of, or cautioned for (or charged but not yet tried with) any criminal offence (other than motoring offences). This Declaration does not apply to convictions that are deemed spent under the Rehabilitation of Offenders Act 1974.

7) I am not aware of any material facts i.e. circumstances which may be material to the Insurer’s decision on whether to issue me with a policy, the terms of the policy or the amount of premium to charge me. It is your responsibility to provide complete and accurate information when arranging an insurance policy, throughout the life of that policy and when you are renewing it. It is important that you ensure that all information provided, and all statements made on proposal forms, renewal declaration forms and other documents are, to the best of your knowledge and belief, complete and accurate. Failure to disclose any material information to your insurers could invalidate your insurance cover and could mean that all or part of a claim will not be paid or your policy cancelled. The documents provided are important as they form the basis of insurance contract between the insurer and you the consumer. You should review and confirm that the answers contained within are true and accurate. If you have any doubts as to whether any information is material it should be disclosed. My turnover does not exceed £999,999.

8) I have read the summary of cover and terms of business.

9) Unless I am applying for student insurance, I agree to return a signed declaration and copies of my qualifications certificates (these can be sent by email). I understand that Holistic Insurance Services will not pay for underpaid postage.