RSA

Broker's Company Name :

Broker's Address :

Your Name :

Your Tel. No :

Your Email :

Your Fax No:

Section A - The Charity

1. Name of Charity

2. Addresses of Charity's Principal Office

Postcode

Telephone

3. Full names of all current Trustees of the Charity:

4. When was the Charity established?

5. The Charity is officially recognised as a charity and is:
*complete as appropriate (one only)

*a. in England or Wales and registered under number

*b. in England or Wales but not required to register

*c. outside England and Wales, being in

6. Principal charitable objects:

These questions relate to the charities and any subsidiaries thereof or other related organisations as per note above.

7. During the last five years:

a. Has the name of the Charity changed?

Yes

No

b. Has any other charity amalgamated with or been merged with the Charity?

Yes

No

If 'Yes', please give details

8. a. To what date were the last Charity accounts made up?

    b. Please state period of accounts if other than 12 months

    c. Were those accounts audited or 'independently examined'?

  Yes

No

    d. Did the auditors qualify their opinion in any way? (If the
        examiner or auditor expresses no concerns about the
        organisations' accounts, accounting procedures or financial
        position , the report is unqualified). * If yes, we will need
        to see a copy of the latest Report & Accounts

  Yes

No

   e. State the gross annual income shown in those accounts:

£

   f. State the total gross Charity assets (i.e. fixed assets +
        investments + current assets) shown in the last balance
        sheet:

£

   g. If the Charity acts as a custodian trustee, state the total
        gross assets in its custody:

£

9. a. Is any Charity named at (1) above incorporated as a body
       corporate? (eg limited by guarantee)

  Yes

No

    b. Does any Charity named at (1) above (whether or not incorporated)
        carry out any of its activity through any separately incorporated
        company (e.g. a trading subsidiary)?

  Yes

No

If 'YES' to (a) and/or (b), please state below:
(i) the name and description of all companies concerned (referred to collectively hereinafter as 'the Companies'), indicating how and when each was incorporated (e.g. the relevant legislation or other legal authority), the relationship between the Charity and the Companies and the activity carried on by each.

10. Do you require Professional Services Cover?

Yes

No

Section B - Professional Services (Optional) extension of cover

Note: The questions in this section must be answered in relation to any 'Professional Services' provided by the Charity. 'Charity' for this purpose means any charity, any of the companies, any present trustee or any present employee of any of them. 'Professional Services' means any service such as advice, information, assistance or design provided to anyone (other than wholly for the purpose of managing or administering the Charity itself), whether gratuitously or otherwise. It does not include the supply of any product. If you are uncertain what in your case constitutes 'Professional Services', please consult your broker or Royal & SunAlliance.

1. Does the Charity provide any of the following Professional services:

*Please note that we may need to see copies of any leaflet's or brochures which
describe the work of and services provided by the charity.

a.* Financial or legal advice?

Yes

No

iv) Approximate number of enquiries per annum?

vi) Where such independent advice is appropriate, is it the usual practice to recommend one or more named advisors?	Yes		No
b.* Counselling?	Yes		No

vi) Where such independent advice is appropriate, is it the usual practice to recommend one or more named advisors?	Yes		No
c.* Medical advice, diagnosis or treatment?	Yes		No

d.* Certification, examination, licensing or regulatory activities or functions?	Yes		No
e.* Other?	Yes		No

11. Do you require Employee Fidelity Cover?

Yes

No

- Employee Fidelity (Optional extension of cover)

1. Has there during the last 5 years been occasion to question the honesty
    of any Trustee/Employee/Volunteer to be insured?

   Yes

   No

If 'YES', please give details:

2. Do all manually prepared cheques and other bank instruments drawn
for more than £2500 require two manually applied signatures to be
added after the amount has been inserted?

Yes

No

If 'NO', what limit is applied:

Are your bankers advised accordingly?

Yes

No

3. Is all the money received banked on the same or next banking day?

Yes

No

4. Number of Employees

5. Wage roll for the last financial year

12. Do you require Event Cover?

Yes

No

- Event Insurance (Optional Extension Of Cover)

1. How many events will you hold during the next year?

2. How many of these events will be held outdoors?

General

1. Has any insurer in respect of the risks to which this proposal relates
ever declined a proposal, refused renewal or terminated insurance?

Yes

No

If 'YES', please give details:

2. Has any claim which might have fallen within the scope of the
proposed insurance been made during the last five years against the
Charity, any of the Companies or any past or present Trustee?

Yes

No

If 'YES', please give details:

3. Is the Charity, any of the Companies or any present Trustee aware,
    after enquiry, of any circumstance or incident which it or he/she has
    reason to suppose might result in any future claim which would fall
    within the scope of the proposed insurance?

Yes

No

If 'YES', please give details:

4. Have you any of the following Insurances in force at present?

Yes

No

If 'YES' please state:

TYPE OF INSURANCE	CURRENT LIMIT OF LIABILITY (£)	RENEWAL DATE	NAME OF INSURER
Trustee Liability
Professional Indemnity
Trustee Fidelity
Employee Fidelity
Event Insurance

5. Is there any other information you would like to provide? eg. Deadline dates, target price, or insured's requirements

Charity Trustee Assurance