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Event Cancellation Proposal Form
In order to obtain a quote for you on this type business we need you to complete the form below - Please note that the form will not allow you to submit to us if you have not answered all the questions - Sorry for having to ask all these questions , but believe it or not it saves you time in us reverting to you with lots of unnecessary questions.
Insured Details:
Name of Insured:
Address:
Town / City:
County:
Country:
eMail:
Telephone number:
Regulatory:
Is the Insured a private individual (a person acting outside their business, trade or profession) ?
Event Details:
Name of Event:
Address:
Town / City:
State/ County:
Country:
Type of Event to be insured:
Has the Event been held before?
Is the Event open to the public?
Event Dates:
Event From Date:
Event To Date:
Adverse Weather:
Will the Event be held wholly or partly in the open air, in a tent, marquee or a temporary structure?
Is cover required for the effects of Adverse Weather?
Does the Event Venue or any area critical to the Event have any history of flooding or exposure to strong winds?
Limits Of Indemnity:
Please provide the following financial information for your Event:
100% Gross Revenue:This is the revenue generated by the event including e.g. admission, sponsorship, etc.
100% Costs and Expenses:These are the costs and expenses paid to third parties for running the event, e.g. event organisers, contractors, etc.
Please select the basis of Indemnity you require:
Non Appearance:
Is coverage required for Non Appearance:
Please note the policy contains a 30 day health warranty and a pre-existing medical condition exclusion
Type of Non Appearance coverage required:
1. First name
Last name
Date of Birth
2. First name
Last name
Date of Birth
3. First name
Last name
Date of Birth
If there are more than 3 persons to be insured please attach additinal names and dates of birth in the space provided
Is any Key Speaker a member of a royal family or serving/former head of state?
1. First name
Last name
Date of Birth
2. First name
Last name
Date of Birth
3. First name
Last name
Date of Birth
If there are more than 3 persons to be insured, please attach additional names and dates of birth in the space provided below.
Simultaneous Non-Appearance for 25% or more of Participants due to Common Accident or Common Illness
Please confirm there are 20 or more performers in total
General Information:
Will all contractual arrangements necessary for the successful fulfilment of each Event be made and confirmed in writing in a prudent timely manner prior to the start of the Event?
Has any Event to be insured had any incidents that could have resulted or did result in a loss which would have been covered under this Insurance during the past three years?
Is the Insured aware of any matter, fact, circumstance or incident existing or threatened that could possibly affect any Event and might result in a claim under the proposed Insurance?
Specific Non Standard Coverage:
Does the Insured have any specific non-standard coverage requirements
Declaration:
Following all due enquiries with and by the Insured I can confirm that to the best of the Insured(s) knowledge and belief the information provided in connection with this proposal is true and the Insured has disclosed any and all material facts. The Insured understands.
A material fact is one likely to influence a reasonable underwriter in determining (a) whether or not to accept the risk; and/or (b) the level of the premium; and /or (c) the terms, conditions and limitations of the certificate. If you are in any doubt as to what constitutes a material fact then please tick no.
Any Additional Information:
Do you have any additional information you would like to state?
  • 1. Insurance is based on the legal principle of "utmost good faith" because you (proposer/insured) are in possession of all the facts that affect the risk you bring to the insurer. It is therefore your responsibility to make a full disclosure of all material facts whether specifically asked or not.
  • 2. Failure to answer any of the questions accurately or to disclose or misrepresent a material fact , including but not limited to all past claims and incidents, might have a bearing on:-
    • (i) the validity of any cover provided by the policy of insurance and/or
    • (ii) the insurers decision whether or not to accept the risk and/or
    • (iii) the outcome of a claim at a later date.
  • 3. Material facts are those facts which might influence the acceptance or assessment of your proposal.
  • 4. All material facts, whether specifically asked or not, should be disclosed. If you are unsure as to whether or not a fact is material, it should be disclosed.
  • 5. The duty of disclosure is continuous and applies at renewal of your policy.
I have read the above notice on completion of forms and understand its contents.
All the information disclosed on it/them, whether completed by me or not, is accurate and is to be treated as if the form/s has/have been completed by me.
I have disclosed everything that might be relevant to this insurance, whether or not I have been specifically asked about it. In particular I have disclosed details of criminal convictions, pending prosecutions, all past claims and incidents
I also confirm receipt and acceptance of the Terms of Business of Burke Insurances Ltd.
In the event of any alteration and/or cancellation to the policy, I agree that Burke Insurances ltd. can deduct their administration fees from any return premium received from the insurer.
I understand that these event insurance type policies are non cancellable and there is no refund in premium or fees for any portion of the premium in the event of cancellation of a policy after inception.
Terms of business
Terms of use
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