Teachers Form

Your Name (required)

Trading as:

Your Email (required)

Address line 1

Address line 2

City

Phone (required)

Type of Classes for the purpose of this insurance: (required)

Are you a member of any Association:(required)
 Yes No

If you are a member of any Association, please give more detail:

Previous Insurers:

Have you ever had any accidents or claims:(required)
 Yes No

Has any Underwriter/Company ever Declined your proposal? (required)
 Yes No

Has any Underwriter/Company ever cancelled or refused to renew a policy? (required)
 Yes No

Has any Underwriter/Company ever required an increased premium or imposed special conditions (required)?

 Yes No

Do you organise summer schools? (required)
 Yes No

EMPLOYERS LIABILITY:-

Do you employ any teachers to assist you? (required)-
 Yes No

I declare to the best of my knowledge and belief that the information given on this form is true and complete in every respect. (required)
 Accept Decline

I agree that this Proposal and Declaration shall form the basis of the Contract between me and the Company.(required)
 Accept Decline

I undertake to inform the company should any facts contained in the Proposal, or additional information rendered, alter in any way. (required)
 Accept Decline

IMPORTANT NOTICE

Failure to disclose material facts could result in your Policy being voided. Material facts are those facts, which might influence the acceptance or assessment of your Proposal. If you are in doubt as to whether a fact is material you should disclose it. A copy of this Proposal Form is available on written request within three months of the date of this Proposal. This cover is UNDERWRITTEN BY ALLIANZ IRELAND p.l.c.

The Company reserves the right to decline any Proposal. Full details of the cover appear in the Policy Document, a specimen of which is available on our website.

OMI is a trading name of O’ Mahony (Insurances) Limited regulated by The Central Bank of Ireland.

Please click here to confirm you have read our Terms of Business.

By proceeding you agree to our Terms of Business which can be viewed here