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Clubs and Bars

Proposal Form

Important Notice:
This form must be completed accurately, in full and in English. All material information likely to
influence the acceptance and assessment of the risk must be disclosed. If it is unknown that the
information will be material or not, provide it otherwise it may affect your policy at a later date.
All values are to be noted in NIS. Please note that this form is not acceptance of confirmation of
cover.
(1)

Applicant Details

Applicant Name:
ID Number/Registration:

Trading as:

Applicant Address:
Business Address:
Home No:

Contact Person Name:

Mobile No:

Business Activity
Description:

(2)

Requested Period of Insurance

Commencement Date:

(3)

Expiry Date:

Proposed Business Information


a) Building Description

Total floors in building:

Floor number of business:

Date building built:

Building made of:

Roof made of:


Owned by applicant

Site is:

Rented/leased

Are any explosives, fuels, chemicals, gases, or any other


exploding and/or self-igniting materials being held or used
in the business or in the building?:
Details:
Are there any other businesses in the building?:

Secured lease

No

Yes (insert details


below)

No

Yes (insert details


below)

Details:
Details of nearby buildings up to 15 metres (type and
use):

(4)

Lien and/or Mortgage and/or Interest to be Noted

Is there any lien or mortgage on the proposed property


and should a lien clause be noted on the policy?:
In favour of:

No

Yes (insert details


below)

Beneficiary address:
The Insurer Providing Cover:
Klapton Insurance Company Limited
Affiliate of NMSIM Group

Klapton Administration Services Provided By:


The Direct Division
Address: 11 Leadenhall Street, London, EC3V 1LP
Tel: +44(0)845 606 7765, Email: info@thedirectdivision.com
Aderia Group Associated

Clubs and Bars


Proposal Form

(5)

Insurance History

No

Are you now, or have you ever been Insured?:


Type of cover

Period of Insurance

Have you ever been declined cover


by an Insurer?

No

Yes (detail)

Has your cover ever been cancelled


by an Insurer?

No

Yes (details)

Have you been refused a renewal


by an Insurer?

No

Yes (details)

Have you been considered for


special terms?

No

Yes (details)

(6)

Loss History

Yes (insert details


below)
Insurer Name

In the last 5 years, have you had any damages or losses or


submitted claims or events?:
Type of cover
Period of Insurance

No

Are you aware of any potential upcoming claims, or any


reason for any claims to arise?:
Details:

No

Yes (insert details


below)

No

Yes (insert details


below)

(7)

Waiver of Rights

(8)

Protection and Safety Measures

Have you given any third party a waiver of your rights to


claim in the event of a loss or damage?:

Insurer Name

Yes (insert details


below)
Sums Insured

To avoid any doubt, according to the policy terms and conditions, the following requirements are essential,
principal and preliminary to provisions of insurance coverage:
(a)
A Protection and Safety Survey will be conducted by a surveyor appointed by the Insurer; the
recommendations and results of this survey will be mandatory for the provision of insurance
coverage.
(b)
A valid Fire Department Inspection Permit, and complete compliance with its recommendations and
requirements.
(c)
The proposed business will be manned at all times. Whenever the business is not manned, all its
entrances will be shut, locked and secured.

I read, understood and accepted


all of the above:
The Insurer Providing Cover:
Klapton Insurance Company Limited
Affiliate of NMSIM Group

Applicants signature:

Klapton Administration Services Provided By:


The Direct Division
Address: 11 Leadenhall Street, London, EC3V 1LP
Tel: +44(0)845 606 7765, Email: info@thedirectdivision.com
Aderia Group Associated

Clubs and Bars


Proposal Form

(9) Details of Requested Cover


Chapter
Chapter and
Selected
Details
Type of Cover
(Y/N)
Chapter 2
Construction
Chapter 3
Contents
Chapter 4
Burglary
Chapter 5
Loss of profits
Chapter 7
Goods in transit
Chapter 8
Cash in safe &
transit
Chapter 9
Terror riots and
malicious damage
Chapter 10
Natural hazards
Chapter 11
Earthquake

0.31%
0.31%

Annual gross profit

0.31%

Maximum per transit

1.63%

Cash in safe
Cash in transit

1.76%
1.76%

Full value of
chapters 2, 3 & 5

0.07%

Full value of
chapters 2, 3 & 5
Full value of
chapters 2, 3 & 5
With 120 allowed
entrants and over:

0.07%

With allowed
entrants of up to
49:
Volume of entrants:

Volume of
Employees:

The Insurer Providing Cover:


Klapton Insurance Company Limited
Affiliate of NMSIM Group

Gross
Premium
(NIS)

0.31%
0.31%
0.31%
0.57%

0.12%
Limit per claimant and
event NIS 4,000,000
Aggregate limit NIS
12,000,000
Limit per claimant and
event NIS 2,000,000
Aggregate limit NIS
4,000,000
Limit per claimant and
event NIS 1,500,000
Aggregate limit NIS
3,000,000
Input actual entrant
volume:

Extension to cover
20% more entrants

Chapter 13
Employers Liability

Rate

Building
Building
improvements
Beverages
Light & sound
equipment
Other contents
All contents

With 50 allowed
entrants and up to
119:
Chapter 12
Public liability

Sum
Insured/Limit

Limit per claimant and


event NIS 6,000,000
Aggregate limit NIS
20,000,000
Limit per Palestinian
employees 10% of
limits

NIS 8,165

NIS 4,600

NIS 2,875

NIS 30 per
entrant
20% of base
premium +
total entrants
charge
NIS 333.50
per employee

Klapton Administration Services Provided By:


The Direct Division
Address: 11 Leadenhall Street, London, EC3V 1LP
Tel: +44(0)845 606 7765, Email: info@thedirectdivision.com
Aderia Group Associated

Clubs and Bars


Proposal Form

Chapter 16
Mechanical
Breakdown

Chapter 17
Mechanical
Breakdown
Consequential Loss

Chapter 18
Electronic
Equipment

Equipment item 1:

0.95%

Equipment item 2:

0.95%

Equipment item 3:

0.95%

Equipment item 1:

0.95%

Equipment item 2:

0.95%

Equipment item 3:

0.95%

Equipment item 1:

2.43%

Equipment item 2:

2.43%

Equipment item 3:

2.43%
Total Rated Premium:
Administration Fee (7%)

Application Total Value (Minimum premium NIS 12,500):

(10)

Excesses/Deductibles

Excesses and deductibles are defined in the Policy Wording. The deductibles below refer to changes and
alterations to the Policy Wording, and the excesses and deductibles below prevail.
Chapter 2 & 3:
In each & every loss or damage NIS 15,000.00. If damage due to malicious act, 10% of the
sum insured subject to a minimum of NIS 62,500.00. There is no aggregated limit for more
than one event &/or claim herein.
Chapter 4:
In each & every loss or damage NIS 25,000.00. Aggregated limit of NIS 150,000.
Chapter 5, 6:
Chapter 7:
Chapter 8:
Chapter 9 & 10:
Chapter 11:
Chapter 12:
Chapter 13:
Chapter 14 & 15:
Chapter 16:
Chapter 17:
Chapter 18:

In each & every loss or damage the first 7 working days will be deducted of each and every
claim. If damage due to malicious act, 10% of the sum insured subject to a minimum of
NIS 62,500.00. There is no aggregated limit for more than one event &/or claim herein.
In each & every loss or damage NIS 10,000.00. There is no aggregated limit for more than
one event &/or claim herein.
In each & every loss or damage NIS 15,000.00. There is no aggregated limit for more than
one event &/or claim herein.
In every single event or occurrence 10% of the total sum insured subject to a minimum of
NIS 50,000.00. There is no aggregated limit for more than one event &/or claim herein.
In every single event or occurrence 10% of the total sum insured subject to a minimum of
NIS 31,250.00. There is no aggregated limit for more than one event &/or claim herein.
In each & every event per single claimant NIS 35,000.00. There is no aggregated limit for
more than one event &/or claimant herein.
In each & every event per single claimant NIS 25,000.00. In the event of a claim resulting
of an Occupational Illness, the deductible will be NIS 35,000.00 per claimant per event.
There is no aggregated limit for more than one event &/or claimant herein.
In each & every event per single claimant NIS 20,000.00. There is no aggregated limit for
more than one event &/or claimant herein.
In each & every loss or damage NIS 20,000.00. There is no aggregated limit for more than
one event &/or claim herein.
In each & every loss or damage the first 7 working days will be deducted of each and every
claim, subject to a minimum of NIS 31,250.00. There is no aggregated limit for more than
one event &/or claim herein.
In each & every loss or damage NIS 10,000.00. There is no aggregated limit for more than
one event &/or claim herein.

The Insurer Providing Cover:


Klapton Insurance Company Limited
Affiliate of NMSIM Group

Klapton Administration Services Provided By:


The Direct Division
Address: 11 Leadenhall Street, London, EC3V 1LP
Tel: +44(0)845 606 7765, Email: info@thedirectdivision.com
Aderia Group Associated

Clubs and Bars


Proposal Form

Application Declaration
1. I hereby declare I know this insurance is administered in the UK with no mediating person outside of the
UK.
2. I know this insurance is executed and placed with a foreign Insurer and I have checked the legality of
the process. I know the Israeli Commissioner does not regulate foreign Insurers.
3. I declare my answers are full, correct and made under my own free will with no facts or material details
omitted that may affect the risk assessment by the Insurer. It is agreed this application will be the basis
for the quote.
4. I know that all questions in this application are considered material information and I do not know any
further information that may affect the Insurers decision as to the cover, its scope and terms.
5. I know and agree that document will be issued in English. The fact that a document is in English, which
may not be my mother tongue, will not be a basis for any claim by me towards the Insurer and the
cover.
6. I know the insurance will become effective only after the Insurer has confirmed cover in writing, and
also only after the premium payment has been made. It is my sole duty to read and pay attention to
the different conditions of the policy.
7. Neither I nor the business proposed for insurance or any employee of mine or of the business proposed
for insurance been convicted of any criminal offense, other than traffic violation in the past 5 years.
8. If the business proposed for insurance legally needs any local license or permit, it is declared and
certified that such license is obtained and valid.
Please note: It is precedent condition to any liability under this policy that the Insured or the
Insureds employees will be present or be in the immediate proximity of the Insured premises at all
times the premises are being used.
Applicants Signature

The Insurer Providing Cover:


Klapton Insurance Company Limited
Affiliate of NMSIM Group

Date

Klapton Administration Services Provided By:


The Direct Division
Address: 11 Leadenhall Street, London, EC3V 1LP
Tel: +44(0)845 606 7765, Email: info@thedirectdivision.com
Aderia Group Associated