Fireworks Display Insurance Proposal Form

Are you an Insurance Broker or Direct Client:

Insurance Broker Company Name:

Financial Services Authority Number:

Insured Company Name (or Insured Person):

First Name

Last Name

Phone/Mobile

Please provide a description of the event:

Has the event been held before?:

Yes

Has the event ever suffered a loss of any kind?:

Yes

Please state the name, address and type of venue?:

When does your event start (date)?:

When does your event finish (date)?:

When will you begin setting up your event at the venue (date)?:

When will you complete breaking down your stand and leave the venue (date)?:

Please state the required value for Public Liability Insurance (or values for multiple quotes):

What is the expected attendance :

Has the 'firer' attended a recognised "Public Firework Display Safety Course" within the last 5years?:

Yes

Has the 'firer' attended and actually launched fireworks at, at least 1 fireworks display in the last 2 years?:

Yes

Has the 'firer' ever had a claim made against him/her, a co-organiser or committee member of any of those events the firer attended?:

Yes

Has the 'firer' ever had any special terms imposed or insurance declined in the past related to events or fireworks only?:

Yes

Have you and all members of the organizing team read and agreed to adhere to HSE’s “GIVING YOUR OWN FIREWORK DISPLAY” document?

Yes

Are you using cat 3 fireworks or below?:

Yes

Do the fireworks and fuses conform to EN 15947 safety standards?

Yes

Have you under taken a risk assessment of the fireworks event? (You may be asked to produce this):

Yes

Please state the number of stewards that will be used to ensure the safe running ofthe event:

Has the permission of the local authority been sought and granted?:

Yes

Has the advice of the local police and/or fire authority been sought?:

Yes

Will either be present during the staging of the event?:

Yes

Is the Venue a secure site?:

Yes

Will alcohol be allowed into the Venue?:

Yes

Will alcohol be on sale at the Venue?:

Yes

Will there be any celebrities present?:

Yes

Will there be any temporary structures including but not limited to Marques and Tiered Seating) at your Event?:

Yes

Will the any structure be inspected by a Local Authority Surveyor? :

Yes

Will suitably qualified staff be in attendance to provide First Aid?:

Yes

Do you require Cancellation Insurance?:

Yes

On which basis do you wish to insure? You may request a quotation for both options?:

Costs, expenses & commitments

Loss of revenue (i.e. total income including profits)

I declare that I have never been 1. Bankrupt 2. Disqualified from being a Company Director 3. Involved as an owner, director, or partner with any company that went into receivership, administration, or liquidation 4. Convicted (or charged but not tried) of any criminal offence involving dishonesty of any kind 5. Organising or attending an event where you have suffered a loss :

Yes