Treatment Risk and Public Liability Insurance

Policy Number

Answer all of the questions below to begin.
Once you have completed the form we will be able to provide you with a quotation.
If your application is successful you can proceed to purchase your insurance online.
When the transaction is completed you will receive your policy documents by email.

It is essential you provide us with ALL MATERIAL FACTS, including: any previous insurance claims made by you for the type of insurance sought. Failure to disclose any material fact may invalidate this insurance, may result in the insurance not operating fully, claims may not be paid, and you may encounter difficulty in trying to purchase insurance elsewhere.

User Role

User Name

Personal Details

Name of Insured*

First Last

Phone Number*

Email Address*

Are you a ROSTI Member?*

The Register of Orthopaedic and Soft Tissue Therapist of Ireland

Yes
No

Please enter your ROSTI Membership Number:

Are you an ARTI Member?*

Athletic Rehabilitation Therapies Ireland

Yes
No

Please enter your ARTI Membership Number:

Are you a NRRI Member?*

National Register Of Reflexologists Ireland

Yes
No

Please enter your NRRI Membership Number:

Are you a CST Member?*

Cranio Sacral Therapist

Yes
No

Please enter your CST Membership Number:

Are you a member of Osteopathic Council of Ireland*

Yes
No

If you are a member of the OCI please contact Sheridan Insurances on 049 438 0020 for a quote.

Are you a member of Chiropractic Association of Ireland*

Yes
No

If you are a member of the CAI please contact Sheridan Insurances on 049 438 0020 for a quote.

Is Student Cover required?

Yes
No

Do you carry out any teaching?*

Yes
No

Do you issue issue any certificates*

Yes
No

Your Postal Address*

Street Address City/ Town County Eircode

Eircode Finder

Insurance Details

Address of Practice*

Same as postal address

Street Address City/ Town County Eircode

Trading Title or Company Name*

Please select your therapies:*

Your Occupation*

Please enter your occupation:

Do you have a recognised qualification for the Occupation you are seeking cover for?*

Yes
No

Please enter your qualification title(s):

Please upload you qualification certificates:*

Drop files here or

Please provide more details:

What is you annual turnover?*

Is the client fully qualified?

Yes
No

Qualification notes:

Who is your current insurer?*

Cover Start Date*

Is the period of cover greater than or less than 12 months?

Yes

Cover End Date*

Public Liability and Products Liability is covered up to:

€4,000,000

Public Liability and Products Liability is covered up to:

€6,500,000

Public Liaiblity

What level of Public Liability cover do you require?

€ 4.5m
€ 6.5m

Employers Liability

Is Employers Liability cover required?*

Yes
No

How many full time staff do you employ?*

How many part time staff do you employ?*

The Premises and Buildings

Is cover required for Property /Material damage? (e.g. Buildings, Contents, Stock, Fixtures & Fittings etc.)*

Yes
No

Are the buildings? (Select as required)*

Built of brick, stone or concrete and roofed with slates, tiles, asphalt, metal or asbestos
In a good state of repair and maintained to keep it in good condition
Select if more than 25% non standard or flat roof

Please give details:*

Is the premises entirely self-contained with its own means of access?*

Yes
No

What age is the oldest part of the building:*

Are the premises protected by intruder alarm?

Yes
No

Alarm Details (Select as required)

Bell only
Central Station Monitored Agreement in Force
Mobile Phone Notification
CCTV

How long are the CCTV records kept, number of months?

Is there a fire alarm?

Yes
No

Is the fire alarm monitored?

Yes
No

Is there a sprinkler system?

Yes
No

Are there smoke detectors?

Yes
No

What type of Heating is in place? (Select as required)*

Oil
Gas
Electric
Portable Heaters
Open fire place /open stoves
Closed stoves

Does the premises provide accomodation for any staff, management, proprietors or directors?*

Yes
No

If yes, please give details:*

Is any food prepared on the premises?*

Yes
No

Type of Cuisine*

What % of turnover relates to outside catering?*

Is all kitchen equipment cleaned regularly and under an annual maintenance contract?*

Yes
No

Do you carry out deep frying on the premises?*

Yes
No

What % of deep frying?*

Cover Required & Sums to be Insured

Buildings (including outbuildings) - sum insured:

Representing full cost of reconstruction in their present form and debris removal and professional fees.

Buildings SI Rate

Buildings Net Premium

Fixtures and fittings - sum insured:

Including contents of common parts, furnishings, fitted carpets and domestic appliances.

Fixtures & Fittings SI Rate

Fixtures & Fittings Net Premium

Tenants Improvements - sum insured:

Value for property maintenance (as per your rental agreement).

Tenants Improvements SI Rate

Tenants Improvements Net Premium

Value of stock on the premises - sum insured:

Stock SI Rate

Stock Net Premium

Value of contents - sum insured:

Contents SI Rate

Contents Net Premium

Value of Computer Equipment - sum insured:

Computer Equipment SI Rate

Computer Equipment Net Premium

Value of Household Contents - sum insured:

Household Contents SI Rate

Household Contents Net Premium

Do you hold money in excess of €10,000 on the premises and do you require cover for this money?*

Yes
No

Amount in excess of €10,000*

Money in excess SI Rate

Money in excess Net Premium

Do you require cover for Business Interruption /Gross Profit?*

Yes
No

Enter Business Interruption /Gross Profit Amount:*

Indemnity period for Business Interruption /Gross Profit:*

12 months
18 months
24 months
36 months

BI /GP SI Rate

BI /GP Net Premium

Is cover required for Goods /Customer Goods in Trust?*

Yes
No

Goods /Customer Goods in Trust - sum Insured:*

Goods /Customer Goods SI Rate

Goods /Customer Goods Net Premium

Is cover required for Goods in Transit in excess of €10,000?*

Yes
No

Goods in Transit in excess of €10,000 - additional sum insured:*

Goods in Transit SI Rate

Goods in Transit Net Premium

Is cover required for own plant, tools and machinery?*

Yes
No

Own plant, tools and machinery - sum insured:*

Plant, tools and machinery SI Rate

Plant, tools and machinery Net Premium

Is cover required for hired in plant?*

Yes
No

Hired in plant - sum insured:*

Hired in plant - SI Rate

Hired in plant Net Premium

Is cover required for Mobile Units?*

Yes
No

Mobile Units - sum insured:*

Mobile Units SI Rate

Mobile Units Net Premium

Is cover required for Fire Brigade Charges in excess of €10,000?*

Yes
No

Fire Brigade Charges in excess of €10,000 - additional sum insured:*

Fire Brigade SI Rate

Fire Brigade Net Premium

Is cover required for Glass in excess of €5,000?*

Yes
No

Glass in excess of €5,000 - additional sum insured:*

Glass SI Rate

Glass Net Premium

Is cover required for rent you pay?*

Yes
No

What is your annual rental payment for the premises?*

Rent Payable SI Rate

Rent Payable Net Premium

Is cover required for rent you receive?*

Yes
No

Value of annual rent you receive.*

Rental Income SI Rate

Rental Income Net Premium

Financial & Claims History

Are you aware of any claims, losses or incidents in the last five years whether insured or not?*

Yes
No

Please provide details of claims or losses:*

Ever been convicted of, cautioned or have a prosecution pending for any criminal offence other than motoring offences?*

Yes
No

Been prosecuted under the health and safety at work act?*

Yes
No

Been declared bankrupt, or been a director of a company that went into liquidation?*

Yes
No

Ever had insurance cover refused, cancelled or special terms imposed?*

Yes
No

Please give details*

Additional Information

Please use this area if you need more space to provide information to the questions or need to provide any material fact that may influence acceptance or assessment of this proposal of Insurance

Refer

Claim Show Premium

Admin Show Premium

No No

No

Frost Underwriting

Customise Premium

Yes

Date of Issue

Change PL LOI

€4,000,000
€4,500,000
€6,500,000

PL Increase or Decrease

PL Net Premium

EL Increase or Decrease

EL Net Premium

MD Increase or Decrease

MD Net Premium

Remove Frost UW Fee

Yes

Comments

Quotation

LR

MR

HR

P1

ROSTI

P1-2

Student

Subtract Risk

P2

ROSTI

P3

ROSTI

ARTI1

ARTI

ARTI2

ARTI

NRRI1

NRRI

CST

Oteopath

Non OCI

Chiropractor

Non CAI

SF

SF1

ROSTI

SF-11

Student Cover

SF2

ROSTI

SF3

ROSTI

SF4

ARTI

SF5

NRRI

SF6

CST

FUW1

ARTI

FUW2

ARTI

FUW3

NRRI

FUW4

ROSTI STUDENT

FUW5

Osteopath

FUW6

Chiropractor

FUW7

CST

EL

MD Calc

MD Min

MD

MD Net Prem

DAS

Net

Net Premium

Price: € 0.00

Government Levy

Price: € 0.00

Stamp Duty

Price: € 0.00

Frost Underwriting Fee

Price: € 0.00

Sheridan Fee

Price: € 0.00

Total

€ 0.00

Quote Status

Reason for Decline

Duplicate submission
Unable to provide cover due to Additional Information provided
Unable to provide cover due to Financial & Claims History

Underwriter Comments

Policy Type

Renewal

Treatment Risk Insurance

Personal Details

Insurance Details

Public Liaiblity

Employers Liability

The Premises and Buildings

Cover Required & Sums to be Insured

Financial & Claims History

Frost Underwriting

Quotation

Quote Status