Personal Accident for Working Parties and Bailiffs Enquiry Form

Personal Accident Insurance for
Angling Club Working Parties & Bailiffs
PROPOSAL FORM
Please provide answers to all questions and give any relevant additional information on this Enquiry Form
Please return the completed Form to
MEAD Sport and Leisure Limited
PO Box 1035,
Smallburgh, Stalham,
Norwich, NR12 9ZL
Any Problems Telephone: 01692 535442
You can scan and then email the form to: [email protected]
www.sportsinsurancemead.com
2
Call our ANGLING HOTLINE
0800 0850 261
for professional advice and immediate cover
CLUB and CONTACT details (please print)
Club Name……………………………………………………………………………………………….................................................
Contact……………………………….……………………Position…………………………………….................................................
Address…………………………………………………………………………………………………..................................................
…………………………………………………………….………….................................................Post Code………………………
Phone……………………………….……………. Mobile............................................................... FAX…………………………...
Email……………………………………………………………………………………………………..................................................
DECLARATION
We declare and warrant that the information provided is, in every respect, true & correct and that we have not withheld any detail that, to our knowledge, would
be likely to affect Underwriters as to our eligibility for insurance. This Enquiry Form and Declaration shall be the basis of the Contract between the Proposer and
the Underwriters and we agree to accept the Underwriters Policy subject to the Terms & Conditions contained therein.
(a) I have read & complied with the requirements of this proposal. (b) I understand that the insurance cover will commence only when this proposal has been
accepted by Underwriters and the premium paid in accordance with the Conditions. (c) I declare that the statements made in this proposal are true & disclose all
information relative to previous claims made or that are pending and any other matter which will assist Underwriters in the assessment of the risk.
Name of Signatory (please print)……………………………………………………………………….........................................
Signature…………………………………………..……………………………………………………...........................................
Position…………………………….………………………..........................................Date……………………………………….
YOUR DUTY OF DISCLOSURE
You must disclose to us all matters, which are relevant to Underwriters deciding whether or not to provide cover and to determine the Conditions of said cover.
In particular you must advise us of any matter which is known to you and which is likely or more likely to lead to a potential claim being made under the policy.
This applies whether we have asked a specific question or not. If you fail to make a full disclosure then your Statutory Rights under the policy and in particular
your rights to make a claim may be prejudiced.
Working Parties/Bailiffs Details (please print)
Number of Parties per annum…………..….......Maximum Attendance…………......
Are they Full or Half Day Parties……………………………………………….............
IF Cover is required for Bailiffs please advise total number of man hours worked per annum............
Is any work carried out in Boats?
NO 
(if YES please give full details below)
YES 
3
Is the work
Cosmetic 
or
Structural 
(Cosmetic work includes collecting debris, strimming undergrowth, grass cutting etc)
If Structural or work involving Power Driven Equipment including Chain Saws please detail below
Insurance Requirements
Insurance Benefit Options:
Death & Disablement
Death & Disablement
£5,000/£25 per week 
£10,000/£50 per week 
Standard Age Limits 16 to 70. Weekly Benefit only payable to those in regular and gainful employment.
Previous disability exclusion Clause. 28 day excess/maximum 52 weeks..
Maximum any one accident clause.
Current Insurer .......……………………………………………………………………........................
Renewal Date……………………….......................
Current Premium £………………………...................................
Is the Club responsible for any Dams or any similar structures YES □ NO □
Standard cover is available for those between the ages of 16 & 70
Cover for anyone 71 or over is subject to application
This Cover can be extended to include BAILIFFS (and Assault)
Use our ANGLING HOTLINE 0800 0850 261 to find out more
Please continue on a separate sheet of paper if necessary
4
Details of the Cover and a Summary and Full Terms and Conditions are
available on request. Cover is Underwritten by Certain Syndicates at Lloyd’s.
MEAD Sport and Leisure Ltd has been authorised by The Financial Services Authority FSA to carry out regulated activities as an appointed
representative of Golfguard limited – FSA Firm Ref Number 310410
January 2015
IMPORTANT
Claims: Please give details overleaf of any relevant claims made over the past 5 years or incidents that could
have led to claims if appropriate insurance had been in place.
MEAD Sport and Leisure Ltd provide a range of insurance products for the angling
community including essential Club Public Liability cover with Employers & Personal
Liability for adults available as extensions. Also available tailored cover in respect of
Buildings, Club equipment & Trophies.
Call our ANGLING HOTLINE 0800 0850 261 for further information.