01245 321185

ACPAT Corporate Professional & Public Liability Insurance Application Form

Date: 27/05/2020

Your Information
Our business liability insurance policy is specifically designed for animal physiotherapists, which ensures you receive tailored cover to safeguard your business.
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
Proposer Information
Where the sole owner is the only practitioner engaged by the company, both names may be included on the same certificate (otherwise the policy will be issued in the name of the business only)
Please list all ACPAT members employed by the business
£
Business or Occupation and Limits of Indemnity
Insured Activities
The policy provides cover for professional and public liability arising from Animal Physiotherapy within the CSP’s scope of Physiotherapy practice

Limits of Indemnity - £5,000,000
£
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
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:
• This policy is issued on an OCCURRENCE basis which only covers claims arising from activities undertaken during the currency of the policy.

• Cover will not commence until this application has been approved and a Quotation issued and accepted.

• Policies will run for 12 months from the agreed start date.

• No activities undertaken prior to commencement of the policy is insured unless agreed and noted in the Retroactive Endorsement.
(Retroactive cover may be available subject to evidence of previous and continuous insurance)
Important Information

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.
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.