01245 321185

ACPAT Member Professional Liability Insurance Application Form

Date: 08/08/2020

Your Information
Our liability insurance policy is specifically designed for ACPAT Members practising Animal Physiotherapy 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
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)
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)
Bloodstock claims restricted to policy indemnity limit or £500,000 whichever is the lower in any period of insurance
Disclosure of Material Facts Declaration
Your Duty of Disclosure

IMPORTANT NOTICE CONCERNING YOUR DUTY TO MAKE A FAIR PRESENTATION OF THE RISK
Before your insurance policy takes effect, you have a duty to make a fair presentation of the risks to be insured under your insurance policy. A fair presentation of the risk is one which discloses to the Insurer every material circumstance which you know of or ought to know of; or gives the Insurer sufficient information to put the Insurer on notice that they will need to make further enquiries for the purpose of revealing those material circumstances, which makes that disclosure referred to above in a manner which is reasonably clear and accessible to the Insurer; and in which every material representation as to a matter of fact is substantially correct, and every material representation as to a matter of expectation or belief is made in good faith.

A material circumstance is one that would influence the Insurer's decision as to whether or not to agree to insure you and, if so, the terms of that insurance. If you are in any doubt as to whether a circumstance is material, you should disclose it to the Insurer.
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.
Please acknowledge acceptance of the following:
DECLARATION AND UNDERTAKING I declare that every statement and particular contained within this proposal form: which is a statement of fact, is substantially correct, and which is matter of expectation or belief, is made in good faith. If any such facts, expectations and/or beliefs materially change before the insurance policy takes effect I undertake to provide details of all such changes to the Insurer in order to comply with my obligation to provide a fair presentation of the risk to be insured under the Insurance Policy. I consent to the processing of any sensitive personal data in order to administer and underwrite this policy. I agree to accept the insurer’s standard form of policy and endorsements for this insurance. I confirm that all persons carrying out activities in accordance with the Business or Occupation as defined above are suitably qualified to do
Personal Data
The insurer for policies underwriting this scheme is RSA Insurance Group plc. (RSA). The scheme is administered on their behalf by Graybrook Hallam.

To arrange and administer your policy RSA 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. LAW APPLICABLE 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 underwritten by Royal & Sun Alliance Insurance plc and arranged by Graybrook Hallam 8 Chandlers Way, South Woodham Ferrers, Essex CM3 5TB Tel: 01245 321185 Email: enquiry@graybrook.co.uk Royal & Sun Alliance plc (No. 93792) Registered in England and Wales at St Mark's Court, Chart Way, Horsham, West Sussex, RH12 1XL.Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority Graybrook Hallam is a Trading Name of James Hallam Limited which is authorised and regulated by the Financial Conduct Authority (FCA) James Hallam Limited is registered in England. Registered number 1632840. Registered Office: 156 South Street, Dorking, Surrey RH4 2HF.