NO CLAIMS DECLARATION
NOTE:
It is a requirement of Insurance cover that this Declaration Form be returned to South Yorkshire Healers duly completed

Please circle the answers to the questions below:

1. Have you ever been convicted of any criminal offence, other than
Motoring, or are there any prosecutions pending? Yes  No

2. Has any insurer ever cancelled, declined or refused to renew, or
accepted the risk at special terms? Yes  No

3. Have you had any claims, or incidents, which could give rise to a claim under the policy
involving negligence, error or omission, or are you aware of any circumstances which may
revert to such a claim or suit being made against you? Yes  No

4. Would you have any objections, should the need arise, to having a police CRB
check or joining a Vetting and Barring Scheme? Yes  No (If you already have a CRB disclosure-please send us a copy)

______________________________________________
If the answer to any of the above is "yes" please give information in the space provided (continue on a separate sheet of paper if necessary) do not sign the declaration below.

__________________________________________

I confirm that I have read, and understood, the above. Yes  No

_______________________________________________

I confirm the answers I have given above are true and that I have not withheld any material fact.

I am aware of no claims, suits or any circumstances which could reasonably lead to a claim being made, or action initiated, against me.

Signed:_______________________________________ Date: _________________

Title:______ Surname:______________________ First Name(s):______________

Address:_____________________________________________________________

__________________________________________ Post Code: ________________

Phone No: ___________________ Email: ________________________________

Please return this form with your application for membership to:
Brenda Diskin, 194 Lindsay Avenue, Sheffield, South Yorkshire, S5 7SG