• Balens Fact-Find Form

  • Thanks for your enquiry.

    To provide you with a quotation for you and/or your business, we'll need you to complete the following questions. Depending on the sections of cover you require, additional questions may appear.
    Please do your best to answer as much as you can, and as accurately as possible.

    If there is anything further that you are unclear about, or you you require any assistance, please don't hesitate to contact our Commercial Department on 01684 580776.

    • Insurance options available to you 

    • There are various insurance options available to you...

      Please read the following information and tick the option(s) that you require.



      Option 1 – Clinics and/or surgeries including options for training schools
      (Professional, Public and Products Liability Insurance for you as a business)

       

      Clinics/surgeries

      The policy will provide cover for the treatment, advice, classes, instruction or therapies that you offer.
      Cover is provided whether the above is carried out by any employed or self-employed person for claims made against the corporate name.
      The cost will be based on the turnover and activities of the business.
      Commercial Legal Expenses Insurance is not automatically included in the package cover provided
      You can opt to add this, and other covers, on later in the form
      Please complete the relevant sections of the proposal form shown below.

      Training schools

      The policy will provide cover for the advice, delivery of courses, supervision of students where your business is providing a certificate of competancy.
      Cover is provided whether the training is carried out by any employed or self-employed person for claims made against the corporate name.
      The cost will be based on the turnover of the business, number of students and activities.
      Commercial Legal Expenses Insurance is not automatically included in the package cover provided
      You can opt to add this, and other covers, on later in the form
      Please complete the relevant sections of the proposal form shown below.

       


      Option 2 - Business Contents/Equipment Cover

      If you own and/or are responsible for insuring business contents/equipment, stock, computers and/or electrical equipment you may wish to consider arranging a business contents policy (known as Business Protection Insurance) to cover loss of or damage to such assets.

      The policy automatically provides cover for Money, Glass, Employers Liability, Public liability & Personal Accident, up to set limits. You have the option to add on cover for Business Interruption, Buildings cover and other business covers.

       

    • Please confirm the insurance option you require*

    • Please read our Terms of Business prior to submitting your application for insurance.

    • Applicant details 
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    • Is the risk address to be covered the same as the postal address?*
    • Would you like to add another risk address?*

    • Currently we can't add more than one risk address via this application process.
      Please either continue through the form or you can speak to one of our advisors on 01684 580776.

    • Is any owner, controller, director or senior manager of the business, or their immediate family or close associates, a politically exposed person (PEP)?*
    • Please provide the details of all PEPs connected to the business*

    • If the PEP status of any connected person changes or they become designated under a sanctions regime, please notify us as soon as possible.

    • Please provide the details of the directors of the business*

    • If the status of any director changes or they become designated under a sanctions regime, please notify us as soon as possible.

    • Please provide the details of the Senior Executive Officers of the business

    • A Senior Executive Officer includes roles such as Managing Director, Chief Executive Officer or Chief Finance Officer.

      If the status of any Senior Executive Officer changes or they become designated under a sanctions regime, please notify us as soon as possible.

    • Does the business have any Ultimate Beneficial Owners who own or control 25% or more of the business*
    • Please provide the details of all Ultimate Beneficial Owners of the business*

    • All individuals who are ultimately directly, or indirectly, entitled to control or exercise the control of the company, either by the way of ownership of 25% or more of voting rights of the company or by way of agreement or similar should be regarded as the principal shareholder/beneficial owner of the company.

    • If any of the following occur, please notify us as soon as possible:

      • the number of Ultimate Beneficial Owners with an interest of 25% or more changes
      • the details of any such Ultimate Beneficial Owner change
      • or any Ultimate Beneficial Owner becomes designated under a sanctions regime.
    • Date business established*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Are you a member of a professional association?*
    • Cover required from*
       - -
      2 digit day, 2 digit month, 4 digit year
    • Buildings 
    • Do you require Buildings Insurance?*
    • Are the buildings within 10 metres of any tree which is more than 3 metres high?*
    • Do you require subsidence cover? (If yes, additional information may be required)*
    • Is the building owned in the name of the company specified on the front page of this application?*
    • Are any interests to be noted on the policy regarding Building Insurance?*
    • If no buildings cover is required, do you require tenant improvements?*
    • Contents 
    • Do you require contents/stock & equipment cover at the business premises?*

    • Please specify amounts below:

    • Do you require cover for contents, stock, electrical and/or other equipment taken away from the business premises, other than laptops and/or mobile phones?*
    • Do you require theft cover for the above portable equipment, arising from theft from an unattended vehicle?*
    • Does any single piece of equipment taken away from the business premises exceed a replacement value of £15000?
    • Do you require cover in the EU/worldwide for equipment taken away from the business premises?*
    • Do you hire out equipment? (If yes, additional information may be required)*
    • Do you lease any equipment from a leasing company?*
    • Do you need to note any financial interests for contents under this policy*
    • Business Interruption Cover 
    • Do you require Business Interruption cover?*
    • Indemnity period required*
    • Do you require Loss of Rent cover?*
    • Loss of rent receivable?*
    • Has the rent receivable amount stated above been included in the annual turnover figure provided in this proposal?*
    • Loss of rent payable?*
    • Rent Payable indemnity period*
    • Is a quotation for terrorism required?*
    • If no to above, do you require Increased Expenses only following Interruption?*
    • Indemnity period required*
    • Premises Information 
    • Is the premises grade I or II* listed or subject to a preservation order?*
    • Do the other occupancies at the building comprise of anything other than residential, retail, office, hotel/guest house &/or surgery/clinic?*
    • Are the walls at the business premises constructed wholly of brick, stone, concrete block, concrete, metal or other non-combustible materials?*
    • Are the floors at the business premises constructed of concrete or timber?*
    • Is the roof at the premises constructed wholly of slate, tile, concrete, metal or other non-combustible materials across at least 80% of the roof area?*
    • Is there any flat roofing at the premises constructed of either felt on timber, fibreglass, rubber or any other non-combustible material?*

    • If yes, please state the construction type(s) and approximate percentage of the total flat roof area for each:

    • Date of last inspection or maintenance visit
       - -
      2 digit day, 2 digit month, 4 digit year
    • Are you responsible for the maintenance of the flat roof under conditions of ownership, lease or tenancy agreement?*
    • Is there a basement at the premises?*
    • If yes to above, do you store any contents, stock or equipment in there?*
    • Are the premises maintained in a good state of repair and will they be so maintained in the future?*
    • Is the business premises in an area that has been previously affected by flooding and/or in an area liable to flooding?*
    • Have there been any previous flood claims/issues at the business premises or have you been informed that your premises is in an area prone to flooding?*
    • Are any of the rooms in your premises sub-let?*
    • Are the premises self-contained with their own separate entrance which is lockable?*
    • Are the premises occupied overnight by the proposer or a family member or employee of the proposer?*
    • Is the business premises due to become vacant, disused, unfurnished and/or empty for a period in excess of 30 days during the forthcoming 12 months?*
    • Are all external doors fitted with 5 lever mortice deadlocks conforming to BS3621?*
    • Are all external, accessible opening windows, including fan lights, fitted with key operated window locks?*
    • Are any of the windows fitted with bars, grilles or shutters? *
    • Are the premises protected by CCTV or perimeter fencing?*
    • Is there an intruder alarm at the premises?*
    • If yes, please confirm that it has been professionally installed*
    • Is the alarm annually maintained?*
    • Is the alarm an intruder alarm with monitored remote signalling to a central station, Level 1 police response, and dual signalling? *
    • Are the premises fitted with an automatic monitored fire alarm?*
    • Is there any other security at the premises, for example any roller shutters, security patrols, perimeter fencing?*
    • Are portable heaters used at the business premises?*
    • Are there any sauna/steam rooms at your business premises?*
    • Employers Liability 
    • Is cover required for Employers Liability? *
    • Do all employees carry out their work exclusively within the UK and never travel overseas for business purposes whilst working for you?*
    • Public liability 
    • Is cover required for Public Liability?*
    • Limit of indemnity required*
    • Is cover required for exhibitions, events or shows during the next 12 months? *
    • Products Liability 
    • Do you require Products Liability cover?*

    • Please note: the limit of indemnity will be the same as the Public Liability section of cover

    • Are all products manufactured by a third party? *
    • Is there rights of recourse in place against the manufacturer?*
    • Do you re-label, re-bottle or re-brand any products?*
    • Do you sell products to the USA/Canada?*
    • Please provide a turnover split between the following territories in relation to your product sales:*
    • Do sales of goods to customers who do not receive advice or treatment from you exceed £30,000 per annum?*
    • Where are your products imported from?*
    • Surgeries & Clinics 

    • Cover includes Professional Liability, Public and Products Liability for the business activities of any health, fitness, wellbeing and beauty organisation and/or practice.

       

      Medical Malpractice/Professional Advice (Professional Liability)


      This aims to indemnify you for all sums that you shall become legally liable to pay as damages, costs and expenses arising from any breach of professional duty due to a negligent act, error or omission, involving a treatment or advice, error which results in possible injury or death to 'the patient/client’. Cover can include treatments, advice, information supply, cosmetic procedures, teaching demonstrations, consultancy etc.


      Professional Indemnity


      This cover provides indemnity for all sums that the insured shall become legally liable to pay as damages, costs and expenses arising from any breach of professional duty due to a negligent act, error or omission, including any act of libel or slander and unintentional infringement of intellectual property rights.

       

    • Do you require professional liability and malpractice insurance for your business, employees or subcontractors?
    • Limit of indemnity required*
    • Do the self-employed therapists/subcontractors have a contract:*
    • Are the self-employed therapists/subcontractors under your direction and supervision?*
    • Are all employees/self-employed therapists resident in the UK, Northern Ireland, Channel Islands & Isle of Man?*
    • Do you check the insurance arrangements for self-employed therapists?*
    • Do you take money on behalf of other therapists?*
    • Do you advertise other therapists as part of your overall operation?*
    • Do you recommend or endorse therapists as part of your overall operation?*
    • Do you undertake clinical trials?*
    • Do you actively target or hold a contract to provide services to an elite sportsperson or team?*
    • Do you work with children and/or vulnerable adults?**
    • Do you have more than '5' employees that carry out this work? *
    • Do you have a safeguarding policy in place?*

    • Please note that an additional safeguarding questionnaire may be required.

    • Do you offer treatment or classes online?*
    • If yes, does the work involve the USA, North America or any territory under their jurisdiction?*
    • Is any machinery used in the performance of any treatment? *
    • Do you sell any products?*
    • Do sales of goods to customers who do not receive advice or treatment from you exceed £30,000 per annum?**
    • Work outside of the UK 
    • Do you travel and undertake work outside the UK?*
    • If yes, does the work involve the USA, North America or any territory under their jurisdiction?*
    • Training schools 

    • Cover includes Professional Liability, Public and Products Liability, for your training activities. Please note, teachers must have the relevant qualifications for subjects being taught.

    • Are you issuing a certificate or qualification of competency to students upon completion of the course?*

    • In order to provide you with a quotation for your training school activities, we will require a supplementary questionnaire completing. This will be forwarded to you once a member of staff has reveiwed your application.
      Please continue to answer the rest of the questions as will be required for quoting.

    • Limit of indemnity required*
    • Your training course 
    • Is there an entry requirement or pre-requisite for the course?*
    • Do all teachers hold a teaching qualification?*
    • Is any teaching provided by person(s) based permanently overseas?*
    • Is the training course provided solely online?*
    • Is the student required to do any case studies?*
    • Will all students be based in the UK, Channel Islands, the Isle of Man and/or N Ireland?*
    • For bodywork qualifications, does the course include Anatomy and Physiology training?*
    • Is the course accredited?*
    • Would you like to add another course?*
    • Additional course 1 
    • Is there an entry requirement or pre-requisite for the course?*
    • Do all teachers hold a teaching qualification?*
    • Is any teaching provided by person(s) based permanently overseas?*
    • Is the training course provided solely online?*
    • Is the student required to do any case studies?*
    • Will all students be based in the UK, Channel Islands, the Isle of Man and/or N Ireland?*
    • For bodywork qualifications, does the course include Anatomy and Physiology training?*
    • Is the course accredited?*
    • More information about your training activities 
    • Do you provide teaching or training to the USA, Canada or any territory under their jurisdiction?*
    • Are students giving treatments to the public under the training school's name?*
    • If you provide treatments or activities to members of the public outside of the training school, please confirm your annual turnover and the split between each area of your business:*
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    • Commercial Legal 

    • Cover includes: Employment disputes and compensation awards, legal defence, disciplinary hearings, contract disputes cover, property protection & personal injury, tax protection and legal helplines as detailed in the policy wording. The policy will pay legal costs up to £250,000 including: Solicitors’ and Barristers’ fees, court costs, expenses for expert witnesses, attendance expenses, accountants’ fees and employment compensation awards. It will also pay the costs of appealing or defending an appeal (inner limits and excesses apply to some sections of cover). A full summary of the level of cover or the policy wording are available upon request.

    • Do you require cover for Commercial Legal Expenses?*
    • Directors and Officers insurance 
    • Do you require cover for Directors & Officers?*

    • Do you require a quotation for the following optional extensions?

    • Entity Cover?*
    • Employment Practice Liability?*
    • Employee Dishonesty*
    • Pension Trustee Liability*
    • Cyber Liability Insurance 
    • Do you require Cyber Liability cover?*
    • General 
    • Have you or any principal, director, partner, (where applicable) ever 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, and are there any prosecutions pending?*
    • Have you or any principal, director, partner (where applicable) ever had any proposal or renewal for insurance declined, cancelled or voided, had a policy withdrawn or suspended, or had special terms or conditions imposed by any insurer?*
    • Have you or any principal, director, partner (where applicable) ever had any claims, losses or incidents, or are you aware of any circumstances, that have resulted in or could give rise to a claim under any policy involving negligence, error or omission?*
    • Please provide details*
    • Have you or any principal, director or partner (where applicable) ever been the subject of, or had proceedings or applications pending for, any winding-up order, receivership, administration, debt relief order, liquidation, individual or company voluntary arrangement, bankruptcy or insolvency, or any County Court Judgment (CCJ)?*
    • Have you or any principal, director, partner, (where applicable) ever been subject to any disciplinary, regulatory or professional proceedings, hearings or investigations, or are you aware of any circumstances that may give rise to such action or to a claim or suit being made against you?*
    • Do you currently have any insurance cover in force for this business, including any policies arranged elsewhere or under any block, group or association arrangement?*
    • Have you or any principal, director, partner, (where applicable) ever had any claims, or are you aware of any circumstances which could give rise to a claim?*
    • Have you or any principal, director, partner (where applicable) ever been prosecuted, received notice of intended prosecution, or been served with a Prohibition Notice in connection with a breach of any health and safety legislation?*
    • Have you or any principal, director, partner (where applicable) ever sold products to any country that is subject to sanction, prohibition or restriction under United Nations resolutions or the trade or economic sanctions, laws or regulations of the European Union, United Kingdom or United States of America?*
    • Are you or any principal, director or partner, (where applicable) ordinarily resident in the United Kingdom (including Northern Ireland), the Channel Islands and or the Isle of Man?*
    • Is your business registered in, and does it operate solely from, the United Kingdom (including Northern Ireland), the Channel Islands and or the Isle of Man?*
    • Declaration 

    • Fair Presentation of Risk

      You have a duty to make a fair presentation of the risk which is to be covered by this policy. Therefore you should ensure that any information you have provided to us and the content is accurate and complete. Where you have provided us with information which relates to matters of your expectation or belief, it does not matter if such information turns out to be inaccurate provided that you acted in good faith when you provided us with such information.

      If you do not comply with your duty to make a fair presentation of the risk, including failing to disclose or misrepresenting a material fact, or disclosing material facts to us in a way which is not clear, and accessible, your policy may not be valid or the policy may not cover you fully or at all.

      A material fact is any fact which could influence our assessment or acceptance of your application for insurance. You must also tell us about any facts or changes which affect your insurance and which have occurred either since the policy started or since the last renewal date.

      If you are not sure whether certain facts are relevant please ask your insurance broker. If you do not tell us about relevant changes, your policy may not be valid or the policy may not cover you fully or at all.
      You must check all information contained within this document immediately and tell us if any details are incorrect. You should keep a written record (including copies of letters) of any information you give us or your insurance broker. Insurance cover does not commence until confirmed by the insurer or Balens Ltd. A Prospectus & Key Facts Summary or a specimen copy of the Policy wording is available on request.

      This Fact Find is a record of information supplied by you or on your behalf or assumptions we have made, about you, your business and your business partners and directors.

    • Fair Processing Notice for Balens Ltd (Balens) and Balens Insurance Finance Services Ltd (BIFS)


      In your dealings with Balens and/or BIFS you may provide information that includes data that is known as personal data. The personal data we collect will include data relating to your name, address, date of birth, wider contact details and where relevant data relating to health or criminal offences or credit history.

      We will process your personal data to allow us to provide you with our services as your insurance broker and/or credit provider in quoting for, arranging and administering your insurances, for statistical analysis, to assess your suitability to our services (profiling) and in arranging insurance premium finance where applicable.

      It will also be used to manage future communications between ourselves about our products and services. You can opt out from receiving such communications at any time by emailing events@balens.co.uk requesting to unsubscribe.

      We will never sell or pass your data to anyone not connected with the products and services we offer. We will only use your data for the purpose for which it was collected, and only grant access to, or share your data within the Balens Group (including BIFS, and Balens Financial Ltd), with our authorised partners and market service providers such as insurers, and where we are required or entitled to do so by law under lawful data processing,

      Our full Privacy Notice is available http://www.balens.co.uk/privacy-notice.aspx If you require further information on how we process your data and our lawful bases for doing so, or would like a hard copy of our Privacy Notice please contact our Data Privacy Representative by emailing dataprotection@balens.co.uk 

    • Date*
       - -
      2 digit day, 2 digit month, 4 digit year

    • Balens is a trading style of Balens Limited. Balens Limited is authorised and regulated by the Financial Conduct Authority, Firm Reference Number 305787. Balens Limited is registered in England and Wales.  Company Registration Number 04931050. Registered Office: Rossington's Business Park, West Carr Road, Retford, Nottinghamshire, United Kingdom, DN22 7SW. Balens Limited is part of the PIB Group.

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