Statement of Fact

Semploy Extra - Statement of Fact

Quotation Number SE/W1029588 Date of Issue 17th November 2015

To be read in conjunction with the Semploy Extra Policy Wording

Quotation Expires On

16th January 2016

Agent Number Agent Reference Agent

80959W Green Insurance Group Quotation Premium Insurance Premium Tax Total Premium

Proposer's Full Name

Mr Karol Maturske

Years In Business

5

£133.48 £12.68 £146.16

Please note that this Statement of Fact forms the basis of the legal contract between you and Ageas Insurance Limited. It is therefore essential that all the information is accurate and true to the best of your knowledge and belief. This Statement of Fact should be read in conjunction with the Policy Wording, click the following link to obtain the Policy Booklet: http://www.ageas.co.uk/documents/commercial/com136-oct-2013-semploy-extra-policy.pdf Alternatively if this document is a printed document, type the internet address into your browser address bar. Should you require a printed version of this booklet please contact your agent. Please make sure you read the Statements contained in the Statement of Fact. It may contain assumed facts. Please contact your agent immediately if any of the Statements are incorrect. Note that you should disclose any information which may influence us in the acceptance or assessment of your insurance. If you are in any doubt as to whether information is material you should disclose it. You are not required to sign this Statement of Fact but you should read it carefully and verify that all the information contained within it and the Quotation Schedule is correct. Any incorrect information must be notified to your agent immediately. Failure to comply with any of these points may invalidate some or all of your cover.

Ageas Insurance Limited Ageas House The Square Gloucester Business Park Brockworth Gloucester GL3 4FA Registered Office Address: Ageas House Hampshire Corporate Park Templars Way Eastleigh Hampshire SO53 3YA Registered in England and Wales No. 354568 Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.

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Semploy Extra - Statement of Fact To be read in conjunction with the Semploy Extra Policy Wording

Quotation Number SE/W1029588 Date of Issue 17th November 2015

Whenever individual words within the statements appear in bold they have a specific meaning which is defined in the Policy wording under the section headed Definitions. A copy of the policy wording is either included or available from your agent.

Semploy Extra Declaration (Applicable to Whole Policy) Other than the details you have already provided to the Company in respect of any exceptions to the following statements (which if applicable will be shown below the individual declaration statement, in the Declaration Exceptions section or in the General Details section of this Statement of Fact): Has the proposer, any director or partner of the Trade or Business or its subsidiary companies proposed, either personally or in any business capacity:

.

Been declared bankrupt or insolvent or been the subject of bankruptcy proceedings or insolvency proceedings in the UK, Channel Islands, Isle of Man or the equivalent in any other country?

No

Been the owner or director of, or partner in, any business, company or partnership which went into administration, administrative receivership or liquidation, and/or was the subject of any company and/or individual voluntary arrangement with creditors, a winding up order or an administrative order?

No

Been the subject of a recovery action by HM Revenue & Customs or their predecessors?

No

Been the subject of a County Court Judgement (or Scottish, Northern Ireland, Channel Islands, Isle of Man or EU equivalent)?

No

Been disqualified from being a company director?

No

Ever been convicted of or charged (but not yet tried) with or officially cautioned for a breach of any Health and Safety or Welfare or Environmental Protection legislation or been served with a prohibition or improvement order under health and safety legislation?

No

Been convicted of, or charged (but not yet tried), with any criminal offences involving dishonesty, arson, theft, or causing wilful damage?

No

Has the proposer, any director or partner of the Trade or Business or its Subsidiary Companies, in any business capacity, ever had a proposal for insurance declined, renewal refused or special conditions imposed by any insurer?

No

Has the proposer, any director or partner of the Trade or Business or its Subsidiary Companies, in any business capacity, made any insurance claim, been claimed against or suffered any event or loss which may lead to a claim for any of the covers provided by this policy (whether previously insured or not) in the last 5 years except as declared under General Details of this Statement of Fact?

No

. . . . . .

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Semploy Extra - Statement of Fact To be read in conjunction with the Semploy Extra Policy Wording

Quotation Number SE/W1029588 Date of Issue 17th November 2015

Semploy Extra Declaration Exceptions (Applicable to Whole Policy) None

General Details (Applicable to the Whole Policy) Losses or incidents giving rise to losses in the last 5 years: Date

Section

Cause of Claim or Loss

Total Paid

Total O/S

None

Material Facts (Applicable to the Whole Policy)

.

.

. . .

Can the proposer comply with the following work exclusions:

-

Handling or use of silica, asbestos or substances containing asbestos, acids (other than brick acid), gases, explosives, radioactive or similar dangerous liquids or substances?

Yes

-

Use of cradles, hoists and tower cranes?

Yes

-

Contracts consisting solely of demolition or partial demolition?

Yes

Can the proposer confirm there is no construction of, or work in or on the following locations:

-

Towers, steeples, chimney shafts, blast furnaces, dams, canals, viaducts, bridges or tunnels?

Yes

-

Aircraft, airports, railways, ships and other watercraft exceeding 20 metres in hull length, docks, piers, wharfs, breakwater or sea walls?

Yes

-

Collieries, mines, chemical works, gas works, oil refineries, power stations, nuclear installations or establishments?

Yes

-

Mainframe computer or server suites?

Yes

Manual/Non-manual (other than clerical) work outside of the EU?

Yes

Do payments to bona-fide sub-contractors exceed 25% of the annual turnover?

No

Does the number of manual/non-manual workers, not including clerical workers, engaged in the Business proposed (including direct Employees, labour only sub contractors and trainees/ apprentices, principals, partners and directors), including any subsidiary companies the subject of this insurance, exceed 10?

No

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Semploy Extra - Statement of Fact To be read in conjunction with the Semploy Extra Policy Wording

Quotation Number SE/W1029588 Date of Issue 17th November 2015

Material Facts (Applicable to the Whole Policy) - (continued)

. . . . . .

Insert the total number of manual/non-manual proprietors and partners.

1

Insert the total number of manual/non-manual directors and Employees (including all direct Employees, labour only sub-contractors and trainees), including any employed by subsidiary companies included in this insurance.

0

Insert the number of proprietors and partners whose work is solely clerical in nature e.g. bookkeepers, accountants etc.

0

Insert the total number of directors (who are working within the Business) and Employees whose work is solely clerical in nature e.g. bookkeepers, secretaries etc, including any employed by subsidiary companies to be included in this insurance.

0

Does the proposer require cover for temporary staff?

No

Does the proposer use bona-fide sub-contractors?

No

Material Facts (Applicable to Trade - Pipe Laying)

. . .

Are any contracts involving the construction, repair or surfacing of roads undertaken as part of this Business?

No

Please confirm the maximum depth (below ground level) to which work is carried out as part of this Business - Up to and including 1m Are any contracts involving quarrying, water diversion, piling or underpinning undertaken as part of this Business?

No

Quotation Conditions (Applicable to the Whole Policy) This quotation is subject to:

.

Unless other details disclosed and agreed with the Underwriter A 12 month period of cover unless otherwise stated No losses within the last 5 years except as noted in General Details Our standard Ageas Semploy Extra policy wording

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Semploy Extra - Statement of Fact To be read in conjunction with the Semploy Extra Policy Wording

Quotation Number SE/W1029588 Date of Issue 17th November 2015

This quotation is subject to (continued): For cover requests with EL covers, if not already submitted please note we require the ERN and where applicable, subsidiary company name and ERN within 14 days of going on cover, for ELTO purposes.

.

The following Endorsements apply - see Schedule for full wording: Z241 - Amendment to Section 4 - Legal Expenses SE19 - Depth Limit (1M) Exclusion to Section 1 - Liability SE23 - £250 Third Party Property Damage Increased Excess SE90 - Road Construction - Exclusion to Section 1 Liability SX01 - Underground Services - Condition Precedent to Liability

Notes on Cover Tools and Stock in Transit Note that theft cover restrictions apply if unattended and/or in a Vehicle overnight i.e. between 21:00hrs and 6:00hrs. Number of Workers Note that any increase to the number of workers shown in this Schedule must be delared within 30 days of the change to comply with Policy Conditions.

Please refer to the Policy wording for details.

Please can we draw your attention to the fact that the basis of rating factors are:

. . . . . .

Business description Number of persons engaged within the Business - this should include all working directors, proprietors or partners (depending on the status of your business), permanent Employees, labour-only sub-contractors, temporary Employees or casual assistants, part-time Employees, trainees or apprentices Previous history including any bankruptcies, liquidations etc Previous claims or losses or any events which could lead to a claim Where bona-fide sub-contractors are used, payments cannot exceed 25% of your annual turnover If Contract Works cover has been selected, your annual turnover cannot exceed £1,000,000

Please contact your agent immediately if any of these basis of rating factors are incorrect.

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