Balen Declaration Form

Posted by Rosie Plunkett – Sunday, November 20th, 2016

DECLARATION FORM

I have never been convicted of, or charged (but not yet tried) with any criminal offence, other than motoring offences, or offences that are spent under the Rehabilitation of Offenders Act 1974.

I have never had a proposal or renewal for insurance declined or cancelled; a policy voided, withdrawn or suspended, or special terms imposed by an insurer.

I have had no claims, nor am I aware of any circumstances which could give rise to a claim, under the policy involving negligence, error or omission.

I have never had any disciplinary hearings made against me, nor am I aware of any circumstances which may result in a claim or suit being made against me.

I have never been the subject of a winding-up order or company/individual voluntary arrangement with creditors; or been placed into administration, administration receivership or liquidation.

answer is Yes to any of the above questions, please ensure full details have been disclosed to us in a and accessible manner and have not been misrepresented to us.

By signing the form below I declare that the statements and particulars in this proposal are true and complete. I have made a fair presentation of the risk and have not misrepresented or suppressed any material facts. I agree to the contract of insurance being prepared using the information I have supplied in this form along with any associated information I have supplied. I shall inform you of any material alteration to those facts and/or the information supplied before completion of the contract of Insurance. I can also confirm I have read, understood and agree to accept the Balens Terms of Business letter attached. A copy of the policy wording is attached for your attention.

Important Note: This policy is for individuals only (including proprietor only limited companies). If you employ or use other Health and Wellbeing Professionals or if you take payments, bookings or advertise for other Health and Wellbeing Professionals, this policy may not be suitable – please contact Balens for guidance.

You must be a current member with the Clinical Reflexology Association at all times in order to take out this policy, if you are not or you do not renew your membership with them, the insurance could be declared void.

Signed: …………………………………………………………………… Dated:……………………………………………2016/17

Title: ……………………………………………………..

Surname: ……………………………………………………………….First name………………………………………………….

Trade name: ………………………………………………………………………………………………………………………………………………………

Address: ………………………………………………………………………………………………………………………………………………………

Postcode: ………………………………………………………………..Email: …………………………………………………………..

Phone Number: ……………………………………………………… Date of Birth: ………………………………………………
What date do you require your new policy to start from? ……………………………………………………………………………………………..

Please Tick to confirm the option you require Please enter Total premium payable

£4,000,000

£4,000,000 – Student

Personal Accident

Please state below the activities you require insurance cover for. Please provide us with copies of your qualifications for the activities. Cover will be provided subject to suitable qualifications held.

 

 

 

 

 

 

 

Dated: 2016/17


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