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Paul Jones Insurance Cricket Scheme

Application Form

Please complete the following form and we will get back to you as soon as possible regarding your application.


Contact Details


Do you wish to insure buildings and/or contents? Yes No

    Property Damage - Buildings and Contents

    Building Use Heating Construction
    Pavilion / Clubhouse
    Outbuildings
    Other buildings

    Is any part of the roof flat and/or constructed of timber/asphalt? Yes No
      If 'yes', please provide the approximate percentage
    Are the premises in a good state of repair and will they be so maintained? Yes No
    Have the premises or any adjacent property previously suffered from any Subsidence heave or landslip? Yes No
    Is there any known history of subsidence in the area? Yes No
    Are the premises in an area previously affected by flood? Yes No
    Are the premises at risk of flooding or situated within 250 metres of a watercourse or canal, lake, reservoir, seafront, cliff or similar? Yes No
    Do you take precautions to protect pipes against freezing? Yes No
    Will all combustible waste be cleared and removed from the premises on a daily basis? Yes No
    Has an Intruder Alarm been installed? Yes No
      If so, please tick if this has the following signalling Bells only
      Dial out to specified phone numbers
      BT RedCare
    Has a fire alarm been installed? Yes No
    Is the fire alarm signalling linked to an alarm system? Yes No
    Are you able to comply with the Minimum Standard of Security requirements as noted below? Yes No

      Please advise the security arrangements used.

    Minimum Standards of Security - Level 1

    If in relation to any claim for fire explosion riot civil commotion strikers locked out workers or persons taking part in labour disturbances malicious persons theft or attempted theft covered by this Section if You have failed to fulfil the following condition You will lose Your right to indemnity or payment of that claim.

    Unless agreed otherwise by Us in writing within 30 days of inception of this Policy You must ensure that

    1. Final exit doors are secured as follows
    1a. timber doors by mortise deadlocks having 5 or more levers or conforming to BS3621 with matching boxed strike plate
    1b. aluminium doors by cylinder mortise lock operating a swinging lock bolt
    1c. UPVC doors by key operated multi-point locking devices having 3 or more locking points
    1d. the first closing leaf of double doors must be fitted internally with bolts top and bottom.
    2. All other external doors and internal doors leading to common areas or other premises are secured as follows
    2a. by the means set out in 1 above
    2b. by key operated security bolts fitted top and bottom
    3. All opening windows or rooflights accessible from the ground or via roofs pipe work or other structures are secured by key operated locking
       devices or screwed permanently shut
    4. Any security measures stipulated or agreed by Us in writing. When the Premises are closed for Business all locks fitted to all exit doors must
       be put into effect. Any door or window officially designated a fire exit by the Fire Authority is excluded from these requirements.

    Building Sum Insured
    Pavilion / Clubhouse £
    Outbuildings £
    Other buildings £


    Contents of Clubhouse Sum Insured
    General contents including machinery, plant, fixtures & fittings, stock in trade (excluding wines, spirits and tobacco) and tenants improvements. If cover is required for items in the open or away from the club, please enter the relevant sums insured for these items seperately in the All Risks section. £
    Stock of wines, spirits, cigarettes and tobacco - do not include beers & soft drinks (only available if general contents are insured) £
    Food in freezer - automatically provided with contents cover. £500.00
    Do you require subsidence cover? Yes No
    Do you require terrorism cover? Yes No

    Business Interruption - Gross Profit Basis Is cover required?
    Gross profit up to £25,000 Yes No
    Gross profit up to £50,000 Yes No
    Any other limit? £

    Loss of Licence Is cover required?
    £50,000 Sum Insured Yes No

Do you need Money Insurance? Yes No

    Money Insurance

    Money Insurance - See summary of cover for details of policy limits Yes No
    Money in Gaming Machines - £250 policy limit Yes No
Do you need to insure items in the open or away from the cricket club? Yes No

    All Risk - Items in the open

    All Risk Schedule Value
    Club Cricket Bags and Contents - New replacement cost £
    Club Trophies & Engravings - New replacement cost (cover away from club premises) £
    Cricket Equipment including artificial pitches, netting & poles, covers, sight screens, bowling machines, cameras, laptop computers etc. £
    Groundsmens' Equipment (mowers, rollers, spikers, trailers etc). £
    Tractors (Market Value Applies) £

    Description of any item over £1,000 in value

    Make Model Chassis Number Value
    £
    £
    £

Liability Insurance

Liability Indemnity Limits
Employers Liability £10,000,000
Public & Products Liability £5,000,000
Legal Expenses £50,000
Is a Certificate of Employers Liability required? Yes No
Are sporting activities other than cricket to be included? Yes No
    If Yes, please advise what sports & how many teams for each.
Is the Clubhouse open all year round? Yes No
    If No, please advise opening periods
Are your premises let out to non-members for private functions? Yes No
    If yes, please give details
Do you have hazardous activities? e.g. Bonfire Nights? Yes No
    If yes, please give details

Do you wish to insure for Personal Accident? Yes No

    Personal Accident

    Personal Accident Number of Units Required (Max 10)
    Number of Units Required
    Number of Senior Teams Playing for the Club
    One unit of cover provides the following benefits.

    1. Fatal accident, loss of sight of one or both eyes, loss of or total loss of use of limb(s), permanent total disablement from any occupation Sum insured
        £3,000.00
    2. Total loss of speech or deafness Sum insured £3,000.00
    3. Cost of dental and optical treatment and cost of repair or replacement of dentures, Spectacles (excluding contact lenses). Sum insured £250.00
    4. Temporary total disablement from attending the insured persons occupation (per week up to a maximum of 104 weeks Sum insured £15.00

General Information

1. How long has the club been established?
2. Has the Club or any Committee Member held any insurances (in respect of the insurance to which thie Application form
    relates) which have subsequently been A) Declined B) Terminated C) Refused renewal D) Subject to special terms?		 Yes No
3. Has the Club or any Committee Member ever been convicted or charged (but not yet tried) with a criminal offence other
    than a motoring offence?		 Yes No
4. Has the Club or any Committee Member ever been declared bankrupt or are the subject of any current bankruptcy
    proceedings or any voluntary or mandatory insolvency or winding up procedures?		 Yes No

If the answer to questions 2, 3 or 4 is Yes, please give details. Enter N/A if not applicable.

Claims Experience Please detail below any claims or losses occuring in the last 3 years. Enter N/A if not applicable.

Year Incident/Claim Details Amount Paid
£
£
£

Claims History

Under the conditions of your policy you must tell us about any Insurance related incidents (such as fire, water damage, theft or and accident) whether or not they give rise to a claim. When you tell us about an incident we will pass information relating to it to a database.

We may search these databases when you apply for insurance, in the event of any incident or claim, or at time of renewal to validate your claims history or that of any person or property likely to be involved in the policy or claim.

You should show these notices to anyone who has interest in the insurance under the policy.

Important - Disclosure

All material facts must be disclosed. Failure to do so could invalidate the policy. A material fact is one which is likely to influence an insurer in the acceptance and assessment of this application. If you are in any doubt as to whether a fact is material then it should be disclosed to the insurer. If any changes in circumstances arise during the period of insurance cover please provide your insurer with details.

A specimen copy of the policy wording is available on request. We recommend you keep a record (including copies of letters) of all information provided to the insurer for your future reference. A copy of the completed application form will be supplied on request within a period of three months after its completion.

Financial Services Compensation Scheme

The Underwriters are members of the Financial Services Compensation Scheme (FSCS) and you may be entitled to compensation from the scheme if we are unable to meet our liabilities under this insurance This depends on the type of business and the circumstances of the claim Such claims are protected for 90% without any upper limit For compulsory classes of insurance the claim will be met in full Further information about the compensation scheme arrangements is available from the FSCS Information can be obtained on request or by visiting the FSCS website at www.fscs.org.uk

I have read and understood the terms and conditions Yes No





Paul Jones Insurance Services Ltd,
Kings House, 316 Shirley Road,
Southampton, Hants, SO15 3HL

Tel: 023 8078 8444
Fax: 023 8070 2536
Email: enquiries@pjis.co.uk

Paul Jones Insurance Services Ltd is authorised and regulated by the Financial Services Authority. The Financial Services Authority website, which includes a register of all regulated firms, can be visited at www.fsa.gov.uk/register or by calling the FSA on 0845 606 1234.

Paul Jones Insurance Services Ltd is registered in England & Wales No. 01093470. Website powered by Ignition
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