Essential Insurance Application Form

Essential Insurance Application Form

About you

Name*

Address*

Postcode*

Telephone Number*

Email*

Your turnover/gross income

Total for the past year £*

Estimate for the current year £*

Where does your income come from?*

% Percentage from United Kingdom

% Percentage from United States of America

% Percentage from Rest of the World

Professional advice

Do you have a talent manager/agency and/or a media lawyer to clear content and/or give advice on the use of social media and contracts?*

If "yes", who?

If "no", do you have your own procedures in place to clear content or have you attended media training in the past 2 years?

Appearances

How many promotional events do you appear in per year?*

How many TV and Radio appearances do you make a year?*

TV Commercials & brand endorsements

Please list the main products and companies that you are contracted with*

Do you currently have a media insurance policy?*
YesNo

If "yes" what is the renewal date?

Content

What is the Nature of the content you speak about?*

Do you comply with regulatory guidelines regarding disclosure of all paid or sponsored posts?*

Do you promote, advertise or endorse any of the following products: Alcohol, medication, vitamins or supplements?*

Do you only ever commence work for others after you have entered in to a signed contract?*

Cover

What cover do you need?*
1. Media Liability2. Public Liability3. Mobile Devices

CLAIMS DECLARATION

In the past 10 years, have you suffered any loss or had any claims (successful of not) against you that fall within the scope of the proposed cover?*
YesNo

If "yes" please provide us with the full details

Are you aware of any facts, circumstances or situation which could lead to you suffering, a loss or claim made against you that falls within the scope of the proposed coverage?*
YesNo

If "yes" please provide us with the full details

It is understood and agreed that with respect to the questions in the CLAIMS DECLARATION section, if such knowledge or information exists any claim or action arising from them will be excluded from this proposed coverage.

I declare that this application form has been completed after proper inquiry and, based on this inquiry, I declare the application contents are true, accurate and not misleading.

I declare that I will immediately notify Hiscox, before any contract of insurance is concluded, of any additional information that I might render the contents of this application untrue, inaccurate, or misleading, or if any new fact of matter arises which is material to the consideration of this application for insurance.

I declare that I understand and agree that if any if the contents of this application are intentionally untrue, inaccurate, or misleading, in any material respect, or if I fail to notify Hiscox of any additional information that might render the contents of this policy of this application untrue, inaccurate, or misleading, in any material respect, then Hiscox is entitled to rescind any policy issued pursuant to this application

I declare that I understand and agree that this application and all materials submitted in connection with this application are incorporated into and form the basis of any policy issued by Hiscox pursuant to this application.

I declare that by signing this application I am representing that I am duly authorised to execute insurance contracts on behalf of the entity applying for this coverage and that all representations (whether verbal or written) made in connection with this application are made on behalf of and shall be fully binding upon such entity.


Signature


Date

GDPR Agreement

About you

Name*

Address*

Postcode*

Telephone Number*

Email*

Your turnover/gross income

Total for the past year £*

Estimate for the current year £*

Where does your income come from?*

% Percentage from United Kingdom

% Percentage from United States of America

% Percentage from Rest of the World

Professional advice

Do you have a talent manager/agency and/or a media lawyer to clear content and/or give advice on the use of social media and contracts?*

If "yes", who?

If "no", do you have your own procedures in place to clear content or have you attended media training in the past 2 years?

Appearances

How many promotional events do you appear in per year?*

How many TV and Radio appearances do you make a year?*

TV Commercials & brand endorsements

Please list the main products and companies that you are contracted with*

Do you currently have a media insurance policy?*
YesNo

If "yes" what is the renewal date?

Content

What is the Nature of the content you speak about?*

Do you comply with regulatory guidelines regarding disclosure of all paid or sponsored posts?*

Do you promote, advertise or endorse any of the following products: Alcohol, medication, vitamins or supplements?*

Do you only ever commence work for others after you have entered in to a signed contract?*

Cover

What cover do you need?*
1. Media Liability2. Public Liability3. Mobile Devices

CLAIMS DECLARATION

In the past 10 years, have you suffered any loss or had any claims (successful of not) against you that fall within the scope of the proposed cover?*
YesNo

If "yes" please provide us with the full details

Are you aware of any facts, circumstances or situation which could lead to you suffering, a loss or claim made against you that falls within the scope of the proposed coverage?*
YesNo

If "yes" please provide us with the full details

It is understood and agreed that with respect to the questions in the CLAIMS DECLARATION section, if such knowledge or information exists any claim or action arising from them will be excluded from this proposed coverage.

I declare that this application form has been completed after proper inquiry and, based on this inquiry, I declare the application contents are true, accurate and not misleading.

I declare that I will immediately notify Hiscox, before any contract of insurance is concluded, of any additional information that I might render the contents of this application untrue, inaccurate, or misleading, or if any new fact of matter arises which is material to the consideration of this application for insurance.

I declare that I understand and agree that if any if the contents of this application are intentionally untrue, inaccurate, or misleading, in any material respect, or if I fail to notify Hiscox of any additional information that might render the contents of this policy of this application untrue, inaccurate, or misleading, in any material respect, then Hiscox is entitled to rescind any policy issued pursuant to this application

I declare that I understand and agree that this application and all materials submitted in connection with this application are incorporated into and form the basis of any policy issued by Hiscox pursuant to this application.

I declare that by signing this application I am representing that I am duly authorised to execute insurance contracts on behalf of the entity applying for this coverage and that all representations (whether verbal or written) made in connection with this application are made on behalf of and shall be fully binding upon such entity.


Signature


Date

GDPR Agreement

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