Continuing Expense Indemnity Insurance
Application Form
www.wwfi.com
1
Please answer All questions in Full. Please provide All attachments where requested.
This Application Form must be signed and dated by the authorised person responsible for obtaining this insurance.
APPLICANT
1.1
Name of Assured:
1.2
Company Address:
http://www.
(Please complete the website address)
Contact Name for this Insurance:
Fax/e-mail:
ASSURED’S BUSINESS INTEREST
2
2.1
Tel:
Description of business activities/ nature of the business:
Anticipated Sales for the next 12 Months
(‘000s)
Actual Sales for last 12 months
(‘000s)
Previous 12 months
(‘000s)
(Please provide a copy of your latest Report and Accounts)
2.2
Fill out for all locations to be insured: (in order of largest USD Daily Continuing expenses * see overleaf for what these expenses are)
Name of Plant
Specify Function eg.
Operational or storage
Exact Address
Daily Continuing
Expenses*
No. of
employees
1.
2.
3.
4.
5.
6.
7.
8.
2.3
Have any of your employees travelled/ are likely to travel to an Ebola affected area (as per the WHO website)
2.4
Do you receive any imported goods from Ebola affected areas (as per the WHO website)
3
BUSINESS CONTINUITY PLANNING
3.1
Is there a pandemic/ business continuity plan in place (attach a copy)
3.2
How often is this plan reviewed and updated?
3.3
Do you have:



Dark websites
Crisis call hotline / call center available
Other means of communicating a crisis to external parties?
Yes / No
Yes / No
Yes / No
Yes / No
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3.4
Do you have use of an external accredited testing laboratory providing full chemical, microbiological and nutritional
profiles?
Yes / No
If “YES”, please provide details:
3.5
Does an external accredited laboratory verify your own on-site accredited laboratory results?
4
Yes / No
LOSS HISTORY
Do you know of any existing situation that may lead to a claim under this policy?
Yes / No
If “YES”, please provide details:
5
LIMIT / RETENTION
Please provide your preferred limit(s) below:
Continuing Expenses
.......
……
……
each and every Insured Event and in the aggregate
Daily Fixed Benefit
.......
……
……
each and every Insured Event and in the aggregate
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DECLARATION
I declare that after full enquiry, the contents of this application form are true and that I have not misstated, omitted or suppressed any
material fact or information. I agree that this application form together with any other information supplied by me shall form the basis of any
contract of insurance which may be affected. If there is any material alteration to the facts and information which I have provided or any new
material matter arises before completion of the contract of insurance, I undertake to inform insurers. I hereby consent to any information I
have provided being processed by you for the purposes of providing insurance claims handling, which may necessitate sharing such
information with third parties.
Signature:
Title:
Date:
.
a)
b)
c)
d)
e)
f)
g)
*For the purposes of this application Continuing Expenses are (please refer to Policy for full terms and conditions):
Continuing Expenses means only those business expenses set forth in a) to g) below that are incurred by You during the Coverage
Period and which are expenses that You would have incurred on a daily, monthly, quarterly or annual basis but which can be attributed to
a normal working day, had the Insured Event not occurred. Continuing Expenses for purposes of this Policy shall be limited to:
Rent, lease, mortgage, property insurance and property tax payments on the Insured Location(s) but not to include any fines, levies, late
payment charges;
employee wages, payroll limited to any person employed under contract or service or apprenticeship prior to the Insured Event;
utility bills and other maintenance or service contracts which existed prior to the Insured Event.
travel expenses limited to any person employed under contract or service or apprenticeship prior to the Coverage Period to a new
location of business within the same state;
diverting post and calls from Your Insured Location (s) to a location which is within the same area code;
warehouse storage facilities for stock which is unexpired, redirected from suppliers and uncontaminated;
catering / cleaning and other third party vendor contracts for day to day contracted duties which existed prior to the Insured Event;
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