The questions below give us a great understanding of your business and what might affect your ability to trade.

In your view, on a scale of 1 (No Effect/Minimal Impact) - 5 (Major Impact/ Cease Trading) how much would your business be affected by:


Physical Damage at the Premises (Fire/Flood etc)

12345

Inability to trade following Physical Damage:

12345

Inability to trade following Technology Collapse:

12345

Accidents at work causing staff illness or injury:

12345

Accidents involving injury, illness or damage caused by you to members of the public or third party property:

12345

Injury, illness or damage caused by products you sell:

12345

Disruption and inability to trade following a criminal cyber attack:

12345

Management failure in relation to Health and Safety, employment disputes or behaviour that causes shareholder reaction:

12345

The theft or misuse of your intellectual property:

12345

Being sued for a lack of provision of bad or negligent advice:

12345




Basic Insurance Information

Unsurprisingly, this is the fundamental information we need to ingather to transact your insurances appropriately, compliantly and legally.

Please pay particular attention to making sure the legal designation of the business is correctly recorded ( including subsidiaries). The PAYE reference number is essential.


Who is completing this Form:

Your Role: (why are my choices limited?)

Business Name:

Trading Name:

Phone number:

Email:

Correspondence Address:

Correspondence Postcode:

Risk Address (if different):

Risk Postcode (if different):

Company Registration Number:Not Applicable

Employee PAYE Reference Number:Not Applicable


From what date would you like the cover to start:

In which sector/industry is your business based:

What is the Legal Status of this business:

You selected "Other" in regards to your businesses Sector/Industry could you tell us more to help us assess your Sector and Industry here, this could include some processes or anything which makes your business unique:

From whom are we permitted to accept instructions in relation to the proposed insurance:ProprietorPartners/DirectorsProfessional AdvisorsStaffBanks/Lenders



Business History

This section deals with the trading and insurance history of the business and any subsidiary companies. Under ‘Previous claims and incidents’ please make sure you confer with senior colleagues and the company accident book to make sure all and any potential claims are revealed.

There have been countless disputed claims over inaccurate, misleading or unrevealed company insurance history and we do not want that to happen to any of our clientele.


How long approximately has the business traded:

Years at this Risk Address:

Years at another address:


Cancellations, Refusals & Declinatures

Has any insurer declined to accept, cancelled or refused to continue any insurance of this nature with the proposer:

YesNo

Please provide details:


Prosecutions and Convictions

Has the Business ever been prosecuted under the Factories Act 1961, Health & Safety at Work Act 1974, the Consumer Protection Act 1987 or any other statutory regulations:

YesNo

Please provide details:


Current Insurance

Do you have a current insurance policy:

YesNo

Insurer:

Renewal Date:


Previous Claims and Incidents

Are there any incidents or losses that would give rise to a potential claim within the last five years:

YesNo

If you have had any insurance claims or incidents that would give rise to a potential claim, please list them below (Excluding Motor Claims):

Date

Type

Circumstances

Settlement

Outstanding



People Insurance Information

This is one of the most important and challenging sections of this form.

It requires asking personal information of all owners, directors partners and senior management who control the business.

Understandably, some people may think this intrusive; however the history of the individuals running the business obviously affects the risk appraisal of the insurers or underwriters. The danger is that something is not revealed later turns out to be significant after the claim has occurred.

This covers everything from County Court Judgements to unspent criminal convictions and personal insurance history.

We are at pains to reassure you that we are not being unnecessarily nosy, merely trying to reveal everything so that an insurer cannot retrospectively claim ‘they did not know’ and that knowing was important to their understanding of the risk.

We do not want to give the insurer or underwriter the ability to make a choice about whether or not to pay your claim, so the more we reveal the less choice they will have .If you give the insurer an open goal, they will put the ball in the net 1,000 times out of 1,000.

It is extremely unlikely that whatever is revealed will make it impossible to insure, but the premium required or the terms terms might vary.


Has any Principal, Partner or Director or any senior management ever been declared bankrupt, or been in a business that has been sequestrated, liquidated or placed into administration:

YesNo

Please provide details:

Has any Principal, Partner or Director or any senior management ever had an insurance proposal declined:

YesNo

Please provide details:

Has any Principal, Partner or Director or any senior management ever been charged with a criminal conviction (excluding motoring convictions):

YesNo

Please provide details:

Has any Principal, Partner or Director or any senior management ever been subject of a County Court Judgement an Involuntary Arrangement, a Company Voluntary Arrangement or a Sheriff Court Decree:

YesNo

Please provide details:

Has any Principal, Partner or Director ever been subject to a recovery action by Customs and Excise or Inland Revenue:

YesNo

Please provide details:

Has any Principal, Partner or Director ever been served with a prohibition or improvement order under health and safety legislation:

YesNo

Please provide details:

Has any Principal, Partner or Director ever been disqualified from holding company directorship:

YesNo

Please provide details:


Claims History for Individual Principal, Partner, Director or senior management

Please note the following question is about the insurance history of the individuals owning, controlling or running the business either in their personal capacity or other business interests (i.e. other directorships, past or present).


Has any Principal, Partner or Director or any senior management sustained any insurable/ physical loss or damage during the last five years in a personal or business capacity in excess of £5,000:

YesNo

Please provide details:

Please provide details of Claims Experience of people from within the business over the last five years:

Date

Insurer

Circumstance

Settlement

Outstanding Amount


Declinatures

Has any insurer refused to continue, cancel or decline insurance cover for any Principal, Partner or Directors or senior management of the Business:

YesNo

Please provide details:


Convictions

Some convictions are regarded as ‘spent’ under the terms of the Rehabilitation of Offenders Act 1974 and need not to be disclosed in applying for insurance. If you are in doubt about whether a conviction is ‘spent’ please provide any details you have for review.


Has any Principal, Partner or Director or Senior Management ever been convicted of or charged (but not yet tried) with arson or any offence involving dishonesty of any kind (e.g. fraud, robbery, theft or handling stolen goods):

YesNo

Please provide details:





Premises Insurance Information

This is an exploration of the physical premises you operate from and includes matters of construction, security and suchlike.

It’s fairly straightforward though you’ll need to know about your own systems around security, fire safety and so on.


What is the property used for:

Are you the Sole Occupier of this Risk Address:

Are adjoining properties occupied:

Are there any unoccupied areas at the Risk Address:

YesNo

YesNoDon't Know

YesNoDon't Know

You selected you are Not the Sole occupier at the address, Please provide details of other occupants:

You selected adjoining properties are Occupied, Please provide details of other properties:

You selected there were Unoccupied area's at the location, Please provide details of other properties:


If there are operational businesses surrounding/ above or below your premises please list the trades these businesses operate in:

Fire Prevention

Has a Fire Risk Assessment been carried out on your premises:

YesNoDon't Know

If so, when was it carried out:

Can you confirm if the premises have appropriate fire extinguishers:

YesNo

Are these subject to an annual maintenance contract:

YesNo

Do the premises have a sprinkler system:

YesNoDon't Know

Do the premises have a fire alarm system:

YesNoDon't Know

Is the fire alarm system linked to remote alarm signalling:

YesNo

Do the premises have a smoke detection system:

YesNoDon't Know

Is this linked to remote alarm signalling:

YesNo

Do you have a closing procedure:

YesNo

As part of your closing procedure do you ensure that there are no smouldering matches, tobacco or hazardous materials within the premises:

YesNo

Upon Discovery of such materials are the potential hazards dealt with:

YesNo


Flood

Have there been any cases of Flood at the premises or in the vicinity:

YesNoDon't know

Please provide details on any flooding at the premises:

Construction

What is the Roof made of:

What are the walls made of:

What is the floor made of:

You selected "Other" for "Roof Construction Material" Please provide details:

Is any part of the roof flat:

YesNo

What % of the roof is flat:


Maintenance

State of repair:Excellent (Constant maintenance programs)Adequate (As and when required)Don’t know

Age of premises:

No of storeys in total:

Storeys occupied by you:

Is the building:

Is there composite panelling:

YesNoDon't Know

What is the Composite Panelling infill:

PolystyrenePUREPSFoamPolyisocyanate (PIR)RockwoolMineral FibreDon't Know

What % is composite panelling:


Subsidence

Are there any subsidence issues at the property or in the area that you are aware of:

YesNoDon't know

Has the property or surrounding area been subject to:

SubsidenceHeavingLandslipDon't Know

Please provide details:


Basement

Is there is a basement:

YesNo

Is the basement used:

YesNo

Is stock kept in the basement at least 10cm off the floor:

YesNo

Do security measures extend to the basement:

YesNo

Please provide details about stock and usage of basement:


Electrical Installation

When was the electrical system installed:

Do you have a valid NICEIC electrical inspection condition report for your premises:

YesNo

When was the NICEIC electrical inspection condition report issued:

Do you have a valid PAT test certificate for your premises:

YesNo

When was the PAT test certificate issued:


Heating

How are the premises heated:

Gas Central HeatingElectric fan heaterOil filled radiatorLPG gas heaterPortable paraffin heaterFixed open fire with flue

Are there any gas or paraffin portable heaters on the premises:

YesNo

Please provide details on any gas or paraffin portable heaters:


Physical Security

Please complete the following questions, soley in relation to security directly and completely under your control. Please advise how each of the following are protected:


Do your locks comply to British Standards 263 (BS263):

YesNoDon't Know

Alarm Contact

Locks

Grills

Bars

Bolts

Shutters

Final Exit Door

Yes

Yes

Yes

Yes

Yes

Yes

Rear Exit Doors

Yes

Yes

Yes

Yes

Yes

Yes

Fire Door

Yes

Yes

Yes

Yes

Yes

Yes

Windows

Yes

Yes

Yes

Yes

Yes

Yes


Is there a fire resistant cabinet in the premises:

YesNoDon't Know


Passive Security Systems

Is there a burglar alarm installed on your premises:

YesNo

Is the alarm installer registered with NICEIC:

YesNo

What is the name of the installer:

Is your alarm under an annual maintenance contract:

YesNo

Who Maintains the alarm system:

Does the alarm system communicate externally:

YesNo

Method of signalling:

Bells OnlyOnline SignallingRedCareDon't KnowOther

Please provide details:


CCTV

Is there a CCTV system fitted to the premises:

YesNo

Is there an external local authority CCTV system monitoring the vicinity:

YesNoDon't Know

Please advise of any other security measures not under your direct control (e.g. security patrols, guard dogs etc):


Waste

How often is waste removed from the premises:

MonthlyFortnightlyWeeklyDaily

How far from the premises is the waste stored:

Is the removed waste kept in metal containers:

YesNo

If not kept in metal containers how is waste stored:


Deterioration of Stock

Are all refrigerated units subject to an annual insurance maintenance contract:

YesNo

Please be aware without a maintenance contract in place the stock will not be insurable


Money

Is cash kept on the premises:

YesNo

How much cash is kept at the premises:

Is Money moved between your premises and the Bank:

YesNo

How much is usually moved:

How often:

By how many people:

Do you take cash home:

YesNo

*Please be aware only monies directly moved between your premises and the bank will be covered by your insurances.


Safe details

Do you have a safe:

YesNo

Make/ Model:

Insurance Rating (if known):

How much money is kept in the safe at peak trading overnight:


Forklifts

Do you use forklifts:

YesNo

How many forklifts are in operation:

Are your forklifts used on public highways:

YesNo

Are forklifts:

If you have charging stations for forklifts are they charged overnight:

YesNo

Are the charging stations at least 5m from any combustible materials:

YesNo





Business Process Insurance Information

This deals with the work you do and the way that you do it. As it’s a universal form, some parts may not apply to your business.


Business Activities

Please provide a full description of business activities:

Are there any manufacturing processes carried out on the premises:

YesNo

What manufacturing processes are carried out:

Are there any flammable oils or other hazardous goods stored or used on the premises:

YesNo

Please provide details:

Does your business involve the use of Frying and Cooking Equipment:

YesNo

Is the Frying Range/Cooking Range annually cleaned by a professional specialist contractor:

YesNo

Who cleans it:

Is the Frying Range/Cooking Range annually serviced by a professional specialist contractor:

YesNo

Who cleans it:

Do you have a valid duct cleaning certificate:

YesNo

Date of last certified clean:

Do you Deliver Food:

YesNo


Are your Drivers:

EmployedAgencySelf Employed

Can you confirm you perform an annual license check for drivers:

YesNo

Can you confirm your delivery drivers are legally able to deliver food on behalf of the business:

YesNo

How do you verify delivery drivers are adequately insured:

Alcohol License

Do the business hold an alcohol license to operate:

YesNo

Please provide details for premises licence holder and licence holders within the premises:

To your knowledge, have there been any objections to the premises having a license during the last five years:

YesNo

Please provide details:

Have the present owner(s) or manager(s) been refused a license at any time:

YesNo

Please provide details:

Are there any circumstances known to the proposer that might prejudice the continued holding of a license:

YesNo

Please provide details:

Do you employ Door Stewards:

NeverOccasionallyConstantly

Are they:

EmployeesAgencySelf Employed

Does the Noise in your premises exceed 85 Decibels:

NeverOftenOccasionallyUnsure

Is there a dance floor within your premises:

YesNo

Are acts of a sexual nature performed as an act of entertainment within your premises:

YesNo


Contractors

Do you ensure that anyone working on your premises has at least a £5 million limit of indemnity on their public liability insurance:

YesNo

How often do you check this is the case:

AnnuallyAt Project Start

Employee Exposure

Do your activities expose your employees to any of the following: excessive noise, working at height or depth, power driven machinery or heat work:

YesNo

Does your process involve

Turnover Excessive noise (higher than 80 decibels):

YesNo

Working at height (10 Meters):

YesNo

Working at depth (3 Meters):

YesNo

Working with naked flame (away from premises):

YesNo

Heat work away from your premises:

YesNo

Power Driven Machinery:

YesNo

High Risk Locations Including Airports, Offshore Installations, Dams, Quarries, Railways, Nuclear Power Stations:

YesNo


Goods Transported within the United Kingdom

Do you collect or deliver stock:

YesNo

If so, do you use you own vehicles:

YesNo

What types of vehicles do you use:

EmployeePrivateCompany

Are employee vehicles insured for business use:

YesNo

How do you verify employee vehicles are insured for business use:

If so, how frequently are your vehicles used:

DailyWeeklyBi-WeeklyMonthlyQuarterlyYearly

What is the maximum value in any one consignment:

How many vehicles are in your care, custody or control:

Do you use couriers:

YesNo

If so, how frequently are couriers used:DailyWeeklyBi-WeeklyMonthlyQuarterlyYearly

What is the maximum value in any one consignment:


Importing / Exporting

Do you:

ImportExportBothNeither

Please provide information on the turnover generated by the business in the following geographic locations:


Region

Import Expenditure

Export Turnover

European Union

North America / USA

Rest of World


What are your sending methods for Goods:

AirLandSea

Do you have any representation outside the United Kingdom:

YesNo


Importing

When Importing do you have legal recourse against manufacturers:

YesNoDon't know


Exporting

If so, do you give advice in connection with products supplied:

YesNo

Have you supplied any goods or services for the nuclear, aerospace, marine or offshore industries:

YesNo

Please provide details:


Pollution

Does your business result in any impairment of the environment e.g. chemical effluents, fumes etc:

YesNo

Please provide details:

Does your business involve the use of toxic and/or hazardous goods, materials, substances and/or waste:

YesNo

Please provide details:

Have you ever been fined/ cautioned/ prosecuted by any environmental agency:

YesNo

Please provide details:


Computers & Data

Do you require insurance protection for the financial consequences of a data loss/breech (Cybercrime):

YesNo

Is the data and maintenance of your computer software and hardware managed by an IT company:

YesNo


Please provide the name of the company and business details of whom manage your IT and Data services:

Please provide answers to the following:


Do you have security controls in place (Antivirus/Malware Protection, Firewalls, Network Access Controls):

YesNo

Do you have backup and recovery procedures in place for all mission critical systems, data and information assets:

YesNo

Do you have processes in place for managing and installing patches on all systems and assets:

YesNo

Do you have processes in place to ensure that all confidential data is encrypted on all portable devices:

YesNo

Do you store more than 100,000 records containing personally identifiable information:

YesNo

Do you have any knowledge of any security failure, operational failure or data breach that would otherwise have been the subject of a claim or loss under a Cyber policy:

YesNo





Assets & liabilities Insurance Information

This is a statement of physical things you want to insure (Assets) Intangible things like future profits ( Business Interruption) and outcomes you are legally responsible for (Liabilities).

Bob gives a series of tips to assist you in compiling the schedule; think about these carefully, we don’t want you being under insured.


Assets

Item

Sums Insured (£)

Bob the Broker's Tips

Are you registered for VAT:

YesNo

If yes, you need not include VAT in the Sums Insured, but if you do 20% is a good cushion against uncertainty.

The Buildings at the risk address

Almost always insured by the owner for the cost of rebuilding including demolition, professional fees, and public authority upgrades

Landlords Loss Rent

Covered in the owner’s policy and on a standard lease usually for 36 months, most often paid by the tenant as part of the lease agreement.

Period of Loss Rent Period

12 months24 months36 months

Tennants Improvements

The cost of making additions or alterations to the Landlord’s Building that would remain to be inherited by the landlord at the end of the lease

External fixed Signage

Signage is expensive and vulnerable to weather and malicious damage, It should be insured for the full cost of replacement

Contents Items (Excluding Stock)

Sums Insured (£)

Machinery, Plant & Equipment

It is important to remember that we need to replace & the equipment as new. It’s the replacement cost on current specification, not the ‘book value’ that’s important

Fixtures & Fittings

This is a mixture of contents and fixtures which you would be able to remove if you were leaving the premises. Items like shop fitting, fixed seating can fall between here and Tenant’s Improvements. Thought required!

Computers & Electronic Hardware

The cost of replacing the equipment, as new. The big & issue here is loss of data and other cyber consequences, but that’s another discussion we need to have Want to have that discussion ?

Discuss Cyber & Data Protection

Portable Devices each individually under £2,000 in value

The cost of replacing as new. This goes beyond phones/laptops – think about specialist equipment you take out of the business.

Stock

Sums Insured (£)

Stock of Alcohol

The wholesale purchase price

Stock of Tobacco

The wholesale purchase price

High Value attractive Stock

Stuff that people would break in for.

Stock in the Open

Stuff that people would climb into the yard for

Chilled & Frozen Foods

You’ll need a maintenance contract to get a claim paid if it’s a breakdown of the cabinet or refrigeration.

All other Stock

Everything that’s not any of the above.

Business Interruption

Sums Insured (£)

For Businesses that Are premises dependent

Annual gross profit: (there is no universal definition for gross profit but if you want the wages paid go with Bob's tips)

This is the gross margin on turnover less cost of sales (usually stock). Not to be confused with Net Profit. The sum insured should look forward to project the trend, not look backwards. Most disastrous business insurance claims are associated by being under insured or for too short a period of interruption. (Except in exceptional circumstances the period should not be less than 24 months probably 36 months)

Number of months covered

6 Months12 Months24 Months36 Months

For Businesses that are Not premises dependent

Annual increased cost of working:

for businesses where turnover is earned ‘away’ from the premises and short term relocation expenses are more appropriate as turnover is less likely to be affected..

Number of months covered

12 Months18 Months24 Months36 Months

Money

Sums Insured (£)

On the premises during business hours:

If the premises were, say held up

In the premises outside business hours:

Contained in locked safes or strongrooms

In the premises outside business hours: but Accessible (in the till)

Leave the tills open, thanks!

At a private residence:

Some people take money home. Not Recommended. Cover is usually limited to £250

In gaming, amusement or vending machines:

First, Check who is responsible for the machine & the money

Cash In Transit

From the premises to the bank:

That’s literal. Don’t go anywhere else. Don’t carry more than £2500.00 in cash per person. Take more people or go more often.

Loss of License

Reduction in value of the premises

as a result of losing an alcohol license, Breweries and Landlords often insist on this, We've never seen a successful claim in 40 years.

Reduction in Gross Profit

as a result of losing an alcohol license this makes more sense, though it's hard to claim as the kind of stupidity that would lead to a claim is routinely excluded from cover. Although we've never seen a successful claim, it is possible, however, so should be considered a risk.

All Risks Specified Items

This would comprise items taken outwith the premises that are individually worth more than £2,000

Item Name

Item Value

Item Description



Liabilities

Wageroll


Please provide estimated annual wages, salaries and all other payments for the next twelve months for full time and part time employees:


Employers have a duty of care to "employees". Compensation is largely based on earnings, so we need to know employee earnings across various types of work and locations.


Working on Premises

Working Away

Activity

Number

Wageroll

Number

Wageroll

Clerical, Non Manual & Managerial

Stewards

Delivery Drivers

Woodworking Machinists

Working at Height (on or above 10 meters)

Working at Depth (at or below 1 meter)

Working with Hazardous Substances (e.g. Asbestos)

Naked Flame & Heat Work

Power Driven Machinery

Other Manual labour

Payments to Bona Fide Sub Contractors

Payments to Labour Only Sub Contractors


Turnover


Turnover measures the activity of a business and is the basis of rating premiums for third party liability, we need to know business turnover split by location and degree of hazard.


Turnover:

Annual Turnover and/or fee income of the business in the last 12 months

Projected Turnover:

Projected Annual Turnover and/or fee income of the business in the next 12 months

Turnover at premises: (%)

Turnover away from premises: (%)


High Risk Locations Turnover


As we provide insurance based on location and degree of hazards it is extremely important that we understand the risk included in the generation of your turnover, as such could you please provide information in regards to percentage of turnover when/if works are undertaken at the following types of high risk locations.


Airports/Airside (%)

Railways/Trackside (%)

Power Stations (%)


Limits of Indemnity

Employers Liability Cover:

£10 Million£5 Million£20 Million

£10 Million is the minimum, only multinationals and big contracts require more

Public Liability Cover:

£5 Million£10 Million£15 Million£20 Million

£5 Million is normal, only those with increased exposure or contract require more

Products Liability Cover:

£5 Million£10 Million£15 Million£20 Million

£5 Million is minimum exports to North America may need more

Management Liability Cover:

£100k£250k£500k£1million

What is the maximum exposure for management misbehaviour?

Cyber Liability Cover:

£250k£500k£1million£5million

If you lose Data, how much else could you lose?

Professional Indemnity Cover:

£250k£500k£1million£5million

Think, whats the most you could be sued for?


Policy Excess

The amount below which you cannot or will not make a claim for reasons of economy and cost of processing.

If you would like to have a premium reduction what amount would you consider increasing your excess to:

£1,000£2,500£5,000




Commercial Insurance Information Declaration

I/We declare that:
a. any data which I have supplied in this Risk Presentation Form about other persons is given with their knowledge and authorisation.

b. the information given in this Risk Presentation Form is correct and complete in every detail.

c. I/we have disclosed all facts and circumstances which would be material to assessment of the risk (whether or not those facts and circumstances were the subject of a specific question in this risk presentation form) and have conducted a reasonable search of the information available to me/us in order to reveal those facts and circumstances.

If there are any material facts or circumstances not specifically covered by a question on this proposal form, I/we have listed them on the Additional Information section below.

d. I/we accept that if I/we have not disclosed all material facts and circumstances then the insurers or underwriters may have grounds to avoid the policy from inception or renewal.

e. Alternatively if the insurers or underwriters would have imposed additional or different terms and conditions to the policy (whether or not those terms and conditions would have been acceptable to me/us) but for my/our failure to disclose all material facts and circumstances I/we accept that the insurers or underwriters may treat the policy as if it had contained those terms and conditions from inception.

f. In addition, if the insurers or underwriters would have charged a higher premium but for my/our failure to disclose all material facts and circumstances, I/we accept that the value of my/our claim may be reduced proportionately in accordance with the formula set out in Schedule 1, paragraph 6 of the Insurance Act 2015 or (if this risk presentation form relates to variation to an existing policy) the formula set out in Schedule 1, paragraph 11 of the Insurance Act 2015.

g. I/we accept and conform to the terms, conditions and exceptions of the Policy ( Click here to download a specimen document) in the standard form issued by the insurers or underwriters for the Insurance now proposed and I will pay the Premiums thereon.

h. I/we consent to the information given in this form, any information the insurers or underwriters may obtain from Fraud prevention agencies or information received with any subsequent claim I/We may make being used in the manner set out in the Privacy Statement as attached.

i. I/we consent for The Business Insurance Bureau discussing information ( both personal and business related) with the insurers and underwriters on my/our behalf.

j. The person signing this Risk Presentation Form is duly authorised to do so on behalf of the prospective insured.

k. I confirm that the person signing Risk Presentation Form has conferred with directors, partners, proprietors and appropriate senior management colleagues in the completion of the form.



Additional Information

Have colleagues contributed to the completion of this Risk Presentation Proposal:

Yes

Please provide details of colleagues who contributed to this Risk Presentation:

Name

Position

I confirm that I am duly authorised by the Proposer to make this declaration.

Signature:

Printed Name:

Position:

Date: