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Proposer Details

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Policy

* Cover is not effective until we have confirmed that it is in force *

Managing Agent

Terrorism

Liabilities
This is the legal liability that you, the insured, assume as landlord for third party death, injury or property damage whilst on the premises.

The ERN is also commonly referred to as ‘Employer PAYE Reference’. This is the reference number provided by HM Revenue and Customs (HMRC) under which the employees’ income tax and NI contributions are recorded. The number is specific to all businesses that employ staff who are individually paid more than the current PAYE threshold. The ERN can be obtained from mandatory HMRC documentation, including P45, P60, P11/D and most payslips.

Disclosure

Premium Funding

I confirm that I have read and understood the following disclosure statement

Would you like a quotation for any of the following:
  • Rent guarantee
  • Insured domestic emergency
  • Management Liability /Directors and officers liability
  • Engineering Insurance

It is a legal requirement world-wide that anyone seeking a new policy of insurance/reinsurance or cover for additional risks or renewal under an existing policy, must disclose any information that might influence the insurers/reinsurers in fixing the premium or determining whether to accept the risk. Under English Law, failure to do so may entitle insurers/reinsurers to avoid cover from inception and seek repayment of paid claims.

If you are in any doubt as to whether information is material, you should disclose it.

We recommend that you print a copy of this form for your records

Arthur J. Gallagher (UK) Limited is authorised and regulated by the Financial Conduct Authority. Registered Office: The Walbrook Building, 25 Walbrook, London EC4N 8AW. Registered in England and Wales. Company Number: 1193013. www.ajginternational.com





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