Commercial Insurance Quote Request Form

To receive a quote for Business Coverage including, but not limited to Property Insurance (Fire, Special Perils & Theft), Business Interruption, Public Liability, Workman’s Compensation and Money, please complete the below quote request and a CapCar Insurance representative will contact you directly to discuss.

Please complete in full.

Note: If you have any questions on How To Calculate Your Sums Insured CLICK HERE

Company Information
Trading Name of Proposer in full:
Name required.
Director/Partners full names(where not shown above):
Full Description of Business or Profession:
Business Address (the Premises):
Mailing Address (if different from above):
Business Telephone:
Business Fax:
Email:
Email Address required.
Please enter a valid email address.
Period of Insurance: From: Start Date required. Please use format dd/mm/yyyy.   To: End Date required. Please use format dd/mm/yyyy.

 

General Information (these are extremely important and must all be answered)
    YES NO
1.  Are your premises, including walls, gates and fences in good repair?
2.  Is your plant and machinery properly fenced, guarded and well maintained?
3.  Are you the sole occupier of the premises? If No give details below.
 
4.  If you have lifts, cranes, hoists, boilers, steam containers or other pressure vessels, are they inspected to comply with all statutory requirements? If No give details below.
 
5.  Will any explosives, explosive chemicals or gases, acids, carcinogens, asbestos or silica or material containing silica, or any other dangerous substances be used? If Yes give precise details below.
 
6.  In the past 5 years, have you suffered any loss or damage (insured or not) by any peril for which insurance is now proposed? If Yes give particulars below.
 
7.  Have you or any principle in the business:  
  (a) Had any previous insurer decline a proposal, refuse to renew a policy or impose special terms and conditions.
  (b) Ever been convicted of or is any prosecution pending for any offence involving dishonesty of any kind (e.g. involving fire, fraud, theft, or handling stolen goods?)
If Yes give details below.
 
8.  (a) Are records of Stock, Sales and Purchasing kept? If No, how would the exact amount of any loss be ascertained?
 
  (b) Are the accounts of the business professionally audited?
9.  Do the premises have:  
  (a) wall built of stone or concrete?
  (b) roof built of Bermuda stone?
  (c) concrete floors throughout?
  If you answered no to any part of question 9, please give details below:
 

 

Property Insurance: Fire, Special Perils & Theft
  YES NO
Is cover to include Theft?
Is petroleum or other mineral oil or liquid product kept on the premises?
Do the premises have an intruder alarm, fire alarm or sprinkler system installed?
If so, please provide details below.
Is the alarm system monitored by a 24 hour central station?

 

Property to be Insured
    Fire & Special Perils Theft
1.  Buildings including Landlords fixtures and fittings. $ $
2.  Loss of Rental Income (if not insured under Business Interruption section). $  
  State number of months cover required for:  months    
3.  Interior Decorations, Improvements and that portion of the building for which you are responsible as a tenant. $ $
4.  Stock and Materials in Trade, including goods held in trust for which the proposer is responsible. $ $
5.  Business Equipment, Furniture, Fixtures & Fittings and all other contents owned by or the responsibility of the proposer but excluding any items already specified above. $ $
6.  Any other property (please give full description). $ $
 
    YES NO
  Do you wish to insure against accidental damage to plate glass windows?
  If so, what is their value? $  

 

Business Interuption
  YES NO
Is cover required?
When is your financial year end?  
Maximum Indemnity Period: months
Note: The indemnity period is the maximum period for which your claim will be covered. It should represent the time necessary for your business to return to full capacity.
Gross profit sum insured: $  
This should include full salary/wages, expenses. See guidelines on how to calculate.
Do you require cover for loss following damage at suppliers or Customers Premises?
If yes, please provide names and percentage of Gross Profit applicable to each, in space provided below.  
Do you require cover for loss following damage at Surrounding Property preventing access to your premises?
Do you require cover for loss following damage at the Premises of Public Utilities?
If yes, what indemnity period do you require? weeks
Do you wish to insure for Outstanding Book Debts?
If yes please state sum insured. $  

 

Public Liability
  YES NO
Do you wish to insure for Public Liability Insurance?
If so what limit of indemnity is required, i.e. $250,000/$500,000? $  
What is your estimated Annual Income? $  
What type of work do you undertake? Please answer below.    
Do you wish to ensure for Products Liability Insurance?
Do you export goods directly, or to your knowledge indirectly to the USA or Canada?
What is the estimated amount of income of goods serviced, maintained, repaired or tested by you? %  
Do you give professional advice or service or provide any form of treatment?
Do you have assets, representation or subsidiaries in overseas countries?
If so which? Please provide details below.
Do you wish to insure any unlicensed mechanically propelled vehicles?
If yes, please provide details below.
Is work undertaken away from your premises?
Do or could any of your processes result in the escape or discharge of any toxic or dangerous substances?
Do you use any process involving heat or welding, away from your premises?
Do you accept liability under contract or agreement for which you would not otherwise be liable?

 

Workmans Compensation
  YES NO
Is cover required for Workmen’s Compensation Insurance?
Do you wish to extend the cover to insure your Common Law Liability?
If yes, what limit of indemnity is required. i.e.$250,000/$500,000? $  


Please provide an estimate of the annual salaries and wages paid to all employees in the box below.

Employee means any person under a contract of service or apprenticeship with the Proposer including labour-only sub contractors. Salaries and Wages means the employees total remuneration including overtime and bonuses.
Description of Type of Work # of Employees Annual Salaries and Wages % of Work Away from the Premises
Clerical and Managerial $
Other Employees (specify types of work below)      
$
$
$
$
Sub-Contractors $
Labour Only Sub-Contractors $
Do any of your employees use Woodworking machinery?
Do you use any processes giving rise to dust or fumes?
Do your employees work on the exterior of building at heights greater than one storey?
Are you aware of any situation where noise may be impairing hearing ability?
Do your premises come under any law or regulation governing the conduct of or maintenance of such premises?
(a) If yes, name them below.
(b) Have you carried out all obligations imposed on you by such law or regulation?
Are you aware of the duties placed upon you by the Health and Safety at Work Act?
Is any work undertaken outside Bermuda?
If so please detail below.

 

Money
  YES NO
Is cover required for Money Insurance?
DEFINITION OF MONEY: Cash, Bank Notes, Cheques, Bankers Drafts, Money Orders, Bills of Exchange, Current Postage Stamps, Credit Company Sales Voucher, all Insured’s own for which he is responsible.
DEFINITION OF BUSINESS HOURS: The period which the Insured’s premises are occupied by the Insured or those employees entrusted with Money.
Business Hours:
How often is Money banked/withdrawn?
How many employees accompany the maximum amount in transit?
How far is your bank from the premises?
How is the journey to the bank made?
Is Money conveyed to or from places other than the bank?
Do you have a safe or strong room in which Money is kept?
If yes give details below of:
Its make or model:
The number of keys and whom held by:  
Are all keys remove from the premise out of business hours?
Is the safe secured to the floor?
What is the estimated ANNUAL amount of money in transit to and from the premises and the bank? $
What limits of liability are required for any single loss arising from:  
(a) Money contained in a locked safe or strong room in the premises out of business hours. $
(b) Money whilst in transit or in the premises during business hours. $

 

Declaration

Please read the following declaration very carefully and read again the questions and answers before agreeing to the Declaration below.

I/We declare to the best of my/our knowledge and belief that
(a) the answers given are true.
(b) All material particulars affecting the assessment of risk have been disclosed.

I/We agree that this Proposal and Declaration shall be the basis of the contract between me/us and the Insurers and shall be deemed to be incorporated in such contract, subject to the terms and conditions of the policy issued by the Insurers. If any answer has been written by any other person, such person shall for that purpose be deemed to be my/our agent and not the agent of the insurers.

 I agree to the declaration above.
You must agree to the declaration before submitting the form.

Liability of the Insurers does not commence until the Proposal has been accepted by the Insurers.

All quotes are subject to medical underwriting. Quotes do not guarantee insurance.