Contractors Combined - Higos

1 Commercial DivisionContractorsCombinedProposal FormContractors CombinedA Policy designed to meet the needs of medium to large Contractors and isdesigned to encompass their insurance needs into one FactsIf required, a summary of the cover available can be provided by your broker or agent in theform of a Key Facts document. A specimen copy of the Contractors Combined policy bookletcan be provided on of PaymentYou can pay your premium in full, via your broker or agent. Alternatively, if your premium is 100 or more, you can choose to pay by monthly by NIG s flexible instalment scheme can ease your cash flow by spreading thepremium payments. A 20% deposit is required with the balance, plus a credit charge, beingspread over 10 equal monthly instalments commencing one month after the date covercommences.

2 Your broker or agent can advise you on the amount of the charge and the interestrate it is based NoteYou must provide all material information likely to influence the acceptance and assessmentof this insurance. If you have any doubts as to whether a fact is material you should discloseit. Failure to disclose any material fact may invalidate your policy or may result in yourpolicy not operating note that the proposal form, declaration and the additional information on theinsurance provided by your broker or agent on your behalf will be the basis of the contractbetween us. NIG Contractors Combined Proposal Form1In completing this form, please tick the appropriate boxes and answer all questions in BLOCK CAPITALSFull Name of ProposerCompany Registration NumberTrading NameBusiness AddressTownCountyWeb Site AddressTrade or BusinessBusiness Phone NoPlease provide a full description of all work currently undertaken or proposed for the future for which cover is requiredHow many year have you been in this trade or business?

3 List any subsidiary companies to be insured Period of Insurance Inception Date Renewal Date 1 Have you or any partner/director in connection with your Business ever suffered any loss, damage,injury or disability or incurred any liability (whether insured or not) during the past 5 years in connection with any of the risks now proposed?YESNOIf yes please give full details below2 Are you now or have you previously been insured for any of the risks now proposed?YESNOIf yes please state name of Insurer, branch, policy number and policy expiry // CodeFOR INTERNAL USE ONLYA gent NameAgency CodeNIG Contractors Combined Proposal Form2 DateType of LossBrief DetailsAmountPaid or Outstanding1 BUSINESS DETAILS2 GENERAL QUESTIONS3 Have you or any partner/director in connection with your Business:-ahad any proposal or insurance declined, cancelled, refused, or made subject to increased rates or special terms?

4 YESNO bbeen convicted of arson or any offence involving dishonesty of any kind ( fraud, theft, etc.)?YESNO cbeen prosecuted under any safety legislation during the last 5 years?YESNO4 Have you or any director or partner or any Company of which any of you have been a director or any partnership of which any of you have been a partner been the subject of a County CourtJudgement (or the Scottish equivalent) or been declared bankrupt or insolvent?YESNOIF YOU HAVE PLACED A TICK IN ANY OF THE SHADED BOXES PLEASE PROVIDE FULL DETAILS BELOW1Do you undertake work:aoverseas?YESNObon nuclear plant/power stations, gas or chemical works, oil refineries/ bulk oil storage facilities, offshore structures, airfields/airports or railway property?

5 *YESNO2 Does any part of your trade or business involve work in connection with:-aquarrying, tunnelling or mining?YESNO bpiling, ground stabilisation, underpinning or dewatering?YESNO ctowers, steeples or chimney shafts?YESNO dbridges, viaducts, flyovers or underpasses?YESNO edocks, harbours, piers or wharfs?YESNO fdams, reservoirs, lakes, rivers, water diversion, flood protection or sea defences?YESNO3Do you work on or have under your control cranes, hoists, passenger lifts or escalators?YESNO4Do you handle or use:-acradles?YESNO bradioactive substances or devices, chemicals, explosives or gases?YESNO casbestos or silica or other material involving a health or safety hazard?YESNO dany other dangerous materials giving rise to dust, fumes or vapours?

6 YESNOIF YOU HAVE TICKED ANY OF THE SHADED BOXES, PLEASE GIVE DETAILS ON ADDITIONAL INFORMATION PAGENIG Contractors Combined Proposal Form32 GENERAL QUESTIONS - continued3 RISK DETAILSNIG Contractors Combined Proposal Form45Do you discharge toxic or dangerous substances into the atmosphere, sewers, waterways or elsewhere?*YESNO6 Have you in connection with sites which you have worked on OR in respect of your Premises (including to your knowledge any former owner or occupant of the Premises)aEver been prosecuted or sued for any pollution problem?YESNObEver had any incidents of pollution or incidents likely to cause pollution?YESNOcEver carried on any industrial activity which was the subject of an environmental permit or licence?

7 YESNOIf yes , give full details* If yes please note that cover for this work cannot be granted until confirmed by NIGIF YOU HAVE TICKED ANY OF THE SHADED BOXES, PLEASE GIVE DETAILS ON ADDITIONAL INFORMATION PAGE7Do you (a) HIRE IN or (b) HIRE OUT any vehicles or plant?YESNOIf yes , please stateaType of vehicle or plantbEstimated annual hire charges for the coming yearcWhich conditions of hire you carry out any processes involving a noise level exceeding 90 decibels?YESNO9Do you handle or use welding or cutting equipment or other equipment or processes involving theapplication of heat away from your premises?YESNO10Is all relevant plant regularly maintained and inspected to comply with statutory regulations?YESNO11 Where Labour & Materials Sub- Contractors (Bona Fide Sub Contractors ) are used, do you check that they are insured for public/products liability insurance in respect of all work they undertakeon behalf during the duration that they work for you?

8 YESNO12 Have you entered into any agreement assuming a liability for injury illness loss or damage for which you would not have been liable in the absence of such agreement?YESNOIf yes , please supply a copy of the YOU HAVE TICKED ANY OF THE SHADED BOXES, PLEASE GIVE DETAILS ON ADDITIONAL INFORMATION PAGEHIRED INHIRED OUT 3 RISK DETAILS - continued1 Which Limit of Indemnity is required? 1,000,000 2,000,000 5,000,000 If any other Limit of Indemnity is required please state estimated number of employees and the annual wages salaries and other payments earnings for the coming Limit 10,000,000 (inclusive of costs and expenses)Do you wish to insure in respect of this Section?YESNOIf yes do you wish to insure against Injuries to Working Partners?

9 YESNODo you wish to insure in respect of this Section?YESNOIf yes please answer section 6 or 7 (as applicable) and section 8 in all Contractors Combined Proposal Form5 Description of OccupationEmployees and Directors engaged in clerical/managerial dutiesEmployees using woodworking machineryWorking Principals and Partners engaged in manual work**A minimum of 15,000 per partner or director must be appliedPlease specify each additional trade/occupationAll other Employees (including those hired or borrowed) andDirectors engaged in manual workLabour only sub- Contractors and self-employed personsLabour & Materials sub- Contractors (specify work)at your premisesNo. away from your premisesNo. Please note that Products Liability is automatically included unless you undertake manufacturing, retailing or wholesaling ofgoods in which case a supplementary proposal form will be required for cover to be PUBLIC LIABILITY5 EMPLOYERS LIABILITYCONTRACTORS ALL RISKSNIG Contractors Combined Proposal Form6 For insurance in respect of a specific contract please complete this Section and Section 81 Name, Address and Postcode of Principal for whom the contract is to be undertaken2 Period of Contract From To3 Period of MaintenanceMonths4 Contract details (please enclose plan)

10 5 Contract Site6 Contract ConditionsFor annual insurance in respect of all contracts please complete this Section and Section 81 Gross annual turnover for the past 3 years2 The maximum estimated gross turnover for the coming year3 Full details of the types of contract undertaken during the past 3 years (work undertaken and contract value)4 Specific details of the largest contract undertaken during the past 3 years (work undertaken and contract value)5 Full details of the types of contracts expected to be undertaken during the next 12 months (work undertaken and contract value) YearGross Annual Turnover 6 SPECIFIC CONTRACT7 ALL CONTRACT (DO NOT COMPLETE IF SECTION 6 COMPLETED)6 Maximum length of any one contract7 Average length of a contract8 Maximum maintenance or defects liability period9 Under what Conditions of Contract is work carried out JCT, ICE?