THE LIGHTWORKERS FOUNDATION
INSURANCE
PROPOSAL FORM
Malpractice/Professional
Indemnity/Public/Products Liability Insurance
(Losses Occurring Basis)
Please complete in blue or black ink. Make sure that everything is legible. This form is scanned electronically. Please answer all questions. No Insurance is in force until confirmation
has been given. The completion of this
form does not bind either you or the insurer in contract.
Name including any trading name
and title (Mr/Mrs/Ms/Miss)
Correspondence Address
Postcode
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Telephone Number
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Email address
Therapies that you wish to cover: Please
enclose a copy of your certificate/diploma
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Therapy |
Dates / Duration of Course |
Teacher / College |
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1 |
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2 |
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3 |
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4 |
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5 |
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Please use a separate sheet if you have
more therapies that you require cover for.
Some therapies not included on the
approved therapies list may require an increase in premium.
Do you maintain clients records and
retain them for at least 7 years?
□ Yes
□
No
Are you a member of any other
Professional Organisation? If yes, please list
□
Yes □ No
Have you ever been subject to a
disciplinary hearing or suspended from any Professional Organisation □ Yes □ No
Do you carry or have you carried
Professional Indemnity Insurance during the last 12 months □
Yes □ No
If yes, please provide
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Name of Insurer |
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Limit of Indemnity |
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Expiry date of the policy |
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Have you had any claims or suits for
negligence, errors or omissions been made against you or are you aware of any
circumstances which may result in any such claims being made against you ` □ Yes □ No
Has any Insurer ever cancelled, declined refused to renew or accepted on
special terms your professional insurance □ Yes □ No
If yes to either of these questions please give details on a separate sheet and
you will be contacted.
Do you wish to have Business Equipment
Cover □ Yes □ No
If yes please tick the level of cover
required:
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£1000 |
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£2500 |
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Date Insurance to commence
I hereby declare and warrant the above
statements and particulars are in all respects complete and true, that they are
material, and that I have not suppressed or misstated any material facts and I
agree that this proposal form shall be the basis of the contract with the
underwriters and deemed to be part of the insurance coverage issued to me.
Signature of Proposer
.
.. Date
.
We cannot accept any proposal
form which is signed/dated more than 30 days prior to the commencement date.
Please return pages 1, 2,
& 4 with copies of your certificates to:
The
LWF Training Centre
Myrtles, 83 Shore
Road, Innellan, Dunoon. Argyll. PA23 7SP.
Holistic Insurance Services is a
trading name of GINS Ltd
The
insurance is underwritten by Novae Insurance Company Ltd
THE LIGHTWORKERS FOUNDATION
MALPRACTICE, PROFESSIONAL INDEMNITY, PUBLIC &
PRODUCTS LIABILITY INSURANCE SCHEME
TO
ARRANGE COVER, FOLLOW THESE INSTRUCTIONS:
The policy is
written on a "Losses
occurring" basis, so as long as the policy is force when the incident
happened, then subject to the policy wording, terms and conditions the claim will
be dealt with by your insurers. The policy includes full retroactive
cover.
1. You
must hold a qualification recognised by Holistic Insurance Services.
2.
Complete
the proposal form and include all documentation
3.
Enclose your cheque for the correct premium payable to
The Lightworkers Foundation
4.
Enclose copies of your Qualification Certificates
5.
Send the above to:
The LWF Training Centre SCMA BCMA Ass.
Myrtles, 83 Shore Road, Innellan,
Dunoon. Argyll. PA23 7SP.
ANNUAL
PREMIUMS:
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Malpractice,
Public & Products Liability* Including retroactive cover for
previously insured periods Libel and slander/breach of
confidentiality Jury Service compensation Legal Helpline** Legal defence costs in respect of
claims made under the policy Legal defence costs in respect of
disciplinary hearings Limit
of indemnity £500,000 *** Legal/accountancy
costs incurred as a result of an Inland
Revenue or VAT investigation Limit
of indemnity £100,000 *** Optional Cover Business Equipment* * Terms and conditions apply. A copy of the policy wording is available
upon request ** Provided by First
Assist *** This section is underwritten on a Claims
Made basis and therefore must be in force at the time a claim is made
against you. |
Limit
of indemnity inclusive of defence costs and
expenses £5,000,000 Up
to £1,000 Up
to £2,500 |
Premium £56.50 £60.00 £80.00 All premiums include
5% Insurance Premium Tax
Administration Fee and use of legal helpline |