Proposal for Professional Fitting and Treatment Liability Insurance

A. Name Of The Proposer In Full

WAAIZ NAZIR

B. Contact Details
Postal Address
(including postcode) ULTIMATE SPEX OPTICIANS. 293 NORMANTON ROAD. DERBY. DE236UU

Telephone: 01332 294599

Fax:

Email: WAAIZ@HOTMAIL.COM

C. Business Premises

Please provide the addresses of all of your business premises.

ULTIMATE SPEX OPTICIANS. 293 NORMANTON ROAD. DERBY. DE236UU

Premises 1

Premises 2

D. Activities

Please provide a full description of your business activities.

OPTOMETRIST

Date Established 2008

E. Products

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 J. Business History

Have you, or any of your business partners or directors:

a) ever been convicted of or charged (but not yet tried) with a criminal offence,
No
other than a motoring offence?

b) been prosecuted during the last five years under any safety or environmental
No
legislation?

c) been involved in any other business in the last five years? No

If so, have any of those businesses been declared bankrupt, insolvent or gone
No
into liquidation?

If ‘Yes’, please give full details, including dates, below

K. Additional Information

Please use this space to provide any additional information which is relevant to your proposal

INSURANCE REQUIRED TO UNDERTAKE EAR IRRIGATION, MICROSUCTION AND WAX REMOVAL

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 L. Important Notice

Please read the following carefully before you sign and date the declaration below.

 The questions on this form and any other details we specifically request relate to the facts considered
material to the underwriting of the insurance. If you answer them fully and honestly, you will be
considered to have fulfilled your duty to disclose material facts. Failure to do so may invalidate your
insurance. If in response to any of these questions you are in any doubt whether a fact is material, you
should disclose it.

 You should also keep your own record (including copies of letters) of all information supplied to us in
arranging this insurance.

M. Declaration

Before signing the declaration please check your answers carefully, particularly if the Proposal Form
is not completed in your own hand.

 I/We declare that to the best of my/our knowledge and belief, the answers given are true and complete.

 I/We agree that if any answers have been completed by another person, such person shall for that
purpose be regarded as my/our agent and acting on my/our behalf, and not the agent of Royal & Sun
Alliance.

 I/We declare that this Proposal Form is for insurance in the normal terms and conditions of the Insurer’s
policy, and shall be incorporated in and form part of the insurance contract.

Signature of Proposer

Date 05/12/2023

Date Cover Is To Start 11/12/2023

This insurance will not commence until the Insurer has indicated their acceptance of the Proposal.
The Insurer reserves the right to decline any Proposal.

PLEASE INITIAL ANY ALTERATIONS ON THIS PROPOSAL FORM

Now return this form to:

Barry Fenton Insurance

99-103 Mary Street
Scunthorpe
North Lincolnshire
DN15 6LA

Tel: 01724 864307

Fax: 01724 868906

Email: insurance@barryfentons.co.uk

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