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ACPAT Member Professional Liability Insurance Application Form

Date: 16/10/2019

Your Information
Our liability insurance policy is specifically designed for ACPAT Members, which ensures you receive tailored cover to safeguard your activities.
You should refer to the policy summary & wording for full details of the insurance cover provided
If you need assistance in completing any of the sections please contact us on 01245 321185
Important Note
All practicing animal physiotherapists engaged by the business must be CSP and ACPAT Members and those engaged on a self-employed or independent basis must maintain Individual Liability Insurance in their own name
Business or Occupation and Limits of Indemnity
Insured Activities
The policy provides cover for professional liability arising from Animal Physiotherapy within the CSP's scope of Physiotherapy practice (Category B Students are subject to the policy supervision clause)

Category A Members

Limits of Indemnity

Professional Liability - Limit of Indemnity £5,000,000 as standard

Public/Products Liability - Not included (provided as part of the CSP's PLI cover for ACPAT/CSP members)
Category B (student) Members

Limits of Indemnity

Professional Liability - Please select limit fo indemnity below

Public/Products Liability - Not included (provided as part of the CSP's PLI cover for ACPAT/CSP members)
Bloodstock claims restricted to policy indemnity limit or £500,000 whichever is the lower
This is an option you should consider if you engage employees, self-employed persons, volunteers (including students on work experience) for whom you may be liable for any work related illnesses or injuries.
The Employers PAYE reference number is usually in the format of either NNN/Aannnnn or NNN/Annnnn,
where N/n is a number and A/a is a letter (e.g. 012/Ab34567)
Disclosure of Material Facts Declaration
Your Duty of Disclosure
See leaflet on the changes introduced by the “Insurance Act 2015” available from our website. It is your duty to ensure sufficient information about your business is provided to insurers that enables them to understand the risks to be insured, or to make further enquiries. You may need to consult with others within your business who may also have relevant knowledge that should be declared to insurers. This duty continues throughout the lifetime of the policy when any change in circumstances should be notified.
Please answer the following:
If Yes please provide the following details

Important Notes:
• Cover will not commence until this application has been approved and a Quotation issued and accepted.
• The policy period will be 12 months from the agreed commencement date.
• If you cease to practice, please refer to us for details of run-off cover.
Please acknowledge acceptance of the following:
Important Information

Personal Data
The insurer for policies underwriting this scheme is AXA Insurance UK plc (AXA). The scheme is administered on their behalf by Graybrook Insurance Brokers Limited.

To arrange and administer your policy AXA and Graybrook Hallam will hold and use information supplied by you, in accordance with U.K. Data Protection Laws and General Data Protection Regulation (GDPR). Full information and your rights about the personal data we collect and process can be found in our Privacy Notice which is available on request and online at www.graybrook.co.uk. A copy of the Privacy Notice will also be included in your quotation/renewal pack.
Unless you select one of these options we will not be able to send information on any of our other insurance policies or services.
We will not sell or pass your information to other organisations for marketing purposes.

CUE - Insurers pass information to the Claims and Underwriting Exchange register, run by Insurance Database Services Limited (IDS Ltd). The aim is to help us to check information provided and also to prevent fraudulent claims. When we deal with your request for insurance, we may search the register. When you tell us about an incident which may or may not give rise to a claim, we will pass information relating to it to the register. You can ask for more information about this.

IPT - Insurance Premium Tax
The Finance Act 1994 requires us to levy Insurance Premium Tax at the prevailing rate on insurance premiums. For further information, please ask us.

The parties to the policy have the right to choose the law applicable to the Policy. Unless the parties agree otherwise English Law shall apply

This Scheme is administered by:

Graybrook Hallam, 8 Chandlers Way,South Woodham Ferrers, Essex, CM3 5TB
Web: www.graybrook.co.uk - Email: enquiry@graybrook.co.uk - Tel: 01245321185 - Fax: 01245 322240
Graybrook Hallam are Authorised and regulated by the Financial Conduct Authority. Registered No. 595238

This scheme is underwritten by:
AXA Insurance UK plc
AXA Insurance UK plc is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.