Ejerforeninger / andelsforeninger
BESTYRELSESANSVARSFORSIKRING
BEGÆRING OM
Ejerforeninger / andelsforeninger
Proposal form for D&O Insurance
(335, 336)
1. GENERELT (General info)
Foreningens navn: Foreningens CVR nr.:
(The association's name) (The Association's registration number)
Foreningens adresse:
(The association's address)
Foreningen e-mail:
(Associations e-mail)
Professionel administrator: Xx
(Professional Administrator) (Yes)
Nej
(No)
Hvis ja, navn:
(If yes, name)
Tlf. administrator:
(Phone number to administrator)
E-mail til administrator:
(E-mail to administrator)
Ønsket ikræfttrædelsesdato:
(Proposed inception date)
(All questions on this proposal form MUST be answered so that the risk can be assessed by the insurers. The completion and signature of this proposal does not oblige the proposer or dahlberg assurance agency a/s to take out an insurance.)
2. ØNSKEDE DÆKNINGER
Markér de ønskede dækninger
(Xxxx the proposed sum insured)
(Sum insured and deductible)
21. Bestyrelsesansvar (Priser anno 2023)
(D&O (Prices as of 2023))
Forsikringssum pr. skade pr. år (Insurance sum per claim per year) | Selvrisiko (Deducible) | Årlig præmie m/ administrator (Annual premium w/ administrator) | Årlig præmie u/ administrator (Annual premium w/o administrator) | Kryds af (Tick off) |
1.500.000 kr. | 10%, maksimalt 2.500 kr. | 982 kr. | 1.412 kr. | |
2.000.000 kr. | 10%, maksimalt 2.500 kr. | 1.308 kr. | 1.882 kr. | |
2.500.000 kr. | 10%, maksimalt 2.500 kr. | 1.637 kr. | 2.353 kr. |
Forsikringssum pr. skade pr. år (Insurance sum per claim per year) | Selvrisiko (Deducible) | Årlig præmie m/ administrator (Annual premium w/ administrator) | Årlig præmie u/ administrator (Annual premium w/o administrator) | Kryds af (Tick off) |
500.000 kr. | 10%, maksimalt 2.500 kr. | 491 kr. | 859 kr. | |
1.000.000 kr. | 10%, maksimalt 2.500 kr. | 982 kr. | 1.719 kr. | |
2.000.000 kr. | 10%, maksimalt 2.500 kr. | 1.964 kr. | 2.700 kr. | |
2.500.000 kr. | 10%, maksimalt 2.500 kr. | 2.455 kr. | 3.376 kr. |
Forsikringssum pr. skade pr. år (Insurance sum per claim per year) | Xxxxxxxxxx (Deducible) |
5.000.000 kr. | 10%, dog maksimalt 10.000 kr. |
3. BETINGELSER FOR OVENSTÅENDE DÆKNINGER (Terms and conditions for the mentioned coverages)
3.1 Ved anvendelse af netbankssystem, har foreningen mindst to bestyrelsesmedlemmer til at godkende enhver disponering af midler.
(When using the online banking system, the association requires a minimum of two board members to approve any fund transactions)
3.2 Foreningens regnskab revideres hvert år af en revisor.
(The association's accounts are audited every year by an accountant)
3.2 Foreningen har ikke haft tab/underskud de seneste 2 år.
(The association has not incurred any losses/deficits in the past 2 years)
2.2 Besvigelse / Underslæb (tillægsdækning) (Priser anno 2023)
(Embezzlement / Misappropriation (additional coverage)(Prices as of 2023))
Ovenstående priser er ekskl. gebyr og afgifter.
(The above prices are excluding fees and taxes)
Foreningsansvar (Fast tillægsdækning uden merpræmie)
Association Liability (Fixed Supplementary Coverage without Additional Premium)
4. TILVALGSFORSIKRINGER (Optional insurance coverages)
Jeg ønsker at modtage en begæring på følgende forsikringer (sæt x):
(I would like to receive a Referral for the following insurances (mark with x))
a. NETBANKSFORSIKRING
(Online Banking Insurance)
Ja
(Yes)
Nej
(No)
b. TERRORFORSIKRING
(Terror Insurance)
Ja
(Yes)
Nej
(No)
5. NYHEDSBREV (Newsletter)
Ønsker du at tilmelde dig dahlbergs nyhedsbrev, der udsendes en gang i kvartalet?
(Do you wish to subscribe to xxxxxxxx'x newsletter, which is sent out once per quarter?)
Ja
(Yes)
Nej
(No)
Hvis ja, angiv venligst e-mailadresse:
(If yes, please provide your email address)
6. SKADER (Claims)
I forbindelse med tegning af ovennævnte forsikring kan vi herved bekræfte, at der ikke har været rejst erstatningskrav mod foreningen, og at foreningen ingen kendskab har til omstændigheder, som kunne resultere i, at et erstatningskrav vil blive rejst.
(In connection with the taking out of the above insurance, we can hereby confirm that no claim for damages has been filed against the association and that the association has no knowledge of circumstances that could result in a claim for damages being raised.)
Dato Underskrift
(Date) (Signature)
7. SAMTYKKE
(Consent)
Opmærksomheden henledes på at:
• Denne begæring behørigt udfyldt tillige med supplerende oplysninger bedes underskrevet af firmaets indehavere eller repræsentant herfor.
• Såfremt forsikring etableres på baggrund af ovenstående oplysninger, skal enhver ændring vedrørende de ovenfor opgivne oplysninger omgående meddeles dahlberg assurance agentur a/s.
Jeg/vi erklærer på tro og love, at ovenstående besvarelser samt supplerende oplysninger er sandfærdige, og at jeg/vi ikke har tilbageholdt eller forvansket nogle forhold. Jeg/vi erklærer endvidere, at der ikke på nuværende tidspunkt foreligger omstændigheder, som måtte lade formode, at noget erstatningskrav refererende til uagtsomme handlinger og/eller undladelser, som nogen af de i virksomheden beskæftigede, herunder indehaverne, har begået. Endelig erklærer jeg/vi at være enige i, at denne erklæring indgår i forsikringsaftalen mellem virksomheden og dahlberg assurance agentur a/s som en del af forsikringsvilkårene.
Please note that:
• This proposal, when duly completed along with additional information, should be signed by the proprietors of the firm or their representative.
• If insurance is established on the basis of the above information, any change regarding the information provided above must be notified immediately to dahlberg assurance agentur a/s.
I/we declare on my honour that the above answers and supplementary information are truthful and that I/we have not withheld or misrepresented any facts. I/we further declare that there are no circumstances at this stage which would suggest that any claim for damages refers to negligent acts and/or omissions committed by any of the employees of the company, including the proprietors. Finally, I/we agree that this statement is included in the insurance contract between the company and dahlberg assurance agentur a/s as part of the insurance terms.
Dato Underskrift
(Date) (Signature)