Application Form - O`Driscoll O`Neil Insurance Brokers

ENROLLED LEARNER PROTECTION BONDS
Private Tertiary Education Establishment (PTEE)
Application Form
New Application
Renewal
PTEE OR COMPANY
Name
Trading As
Address
Phone Number
Email Address
Company Registration Number
Contact Name
CONTACT PERSON
DETAILS OF DIRECTORS OF PTEE
DIRECTOR 1
DIRECTOR 2
Name
Name
Home Address
Home Address
Contact Number
Contact Number
DIRECTOR 3
DIRECTOR 4
Name
Name
Home Address
Home Address
Contact Number
Contact Number
Completed Date of Last Annual Audited Accounts Year
(Please attach latest Audited Accounts and Management Accounts)
Date of Last AGM
Are your tax affairs up to date?
(Please include a copy of your most recent tax clearance certificate with this application)
SOLICITOR’S CONTACT INFORMATION
ACCOUNTANT’S CONTACT INFORMATION
Company Name
Company Name
Contact Name
Contact Name
Address
Address
Phone
Phone
Email
Email
BANK CONTACT INFORMATION
Company Bank
IBAN
Contact Name
Phone
Branch Address
Email
CBL Insurance Europe Limited is regulated by the Central Bank of Ireland
Company Registration Number: 218234
O’Driscoll O’Neil Limited is regulated by the Central Bank of Ireland
Company Registration Number: 249547
DETAILS OF COVER REQUIRED
NUMBER OF PROJECTED ENROLLED LEARNERS ATTENDING SCHOOL PER MONTH
FOR THE CURRENT YEAR AND NEXT YEAR
This Year
Next Year
This Year
January
July
February
August
March
September
April
October
May
November
June
December
Next Year
PROJECTED ACADEMIC FEES FOR ENROLLED LEARNERS ATTENDING SCHOOL PER MONTH
FOR THE CURRENT YEAR AND NEXT YEAR
This Year
Next Year
This Year
January
July
February
August
March
September
April
October
May
November
June
December
Next Year
PROVIDE SPLIT IN ENROLLED LEARNERS BETWEEN
Republic of Ireland
Other EU Countries
Non-EU Countries
QUESTIONS (in all cases where “Yes” answered, please provide full details)
Has there been, or is there likely to be, any material change in the financial condition or capital structure of the school/company
or its associates, or any other matter considered material to the acceptance of this proposal since the last annual report, or
since production of financial data provided with this proposal?
YES / NO
Have any current Enroller Learners or former Enrolled Learners made a claim against your organisation relating to your
organisation’s failure to deliver course curricula?
YES / NO
Does any Director or Officer to be covered by this insurance, after specific inquiry of management and staff, have knowledge of
any material facts or circumstances which could affect your organisation’s ability to meet all its debt as and when it falls due?
YES / NO
Have any courses ever been suspended or discontinued prior to the course being competed?
YES / NO
Has there ever been, or is there now pending, any investigation or prosecution of the school or company or its associates under
any Statute Legislation?
YES / NO
When was your last QQI or Ministry of Education inspection? Within how many months do you expect your next
audit/investigation?
YES / NO
CBL Insurance Europe Limited is regulated by the Central Bank of Ireland
Company Registration Number: 218234
O’Driscoll O’Neil Limited is regulated by the Central Bank of Ireland
Company Registration Number: 249547
PLEASE PROVIDE A FULL LIST OF ALL COURSES INCLUDING COURSE TITLE, COURSE DURATION,
COURSE COST AND ANY OTHER RELEVANT INFORMATION PROVIDED BY YOUR SCHOOL
Course
Title
Course
Duration
Course
Cost
Max.
Places
QQI
Accredited
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Intake
Dates
(* continue on annexed pages if required)
DECLARATION
I, the undersigned, after enquiry, declare as follows:
(a)
I am authorised to make this application.
(b)
I acknowledge the information provided on this proposal is true, factual and correct and is a full disclosure of all material facts relating to this
application. I hereby authorise inquiries by CBL Insurance Europe Limited or its agent for the purpose of approving this application.
(c)
I acknowledge that, at all times, I am under an obligation to immediately advise any change in the particulars or statements contained in this
declaration.
(d)
I acknowledge that this information is required by CBL Insurance Europe Limited (which will be retained by CBL Insurance Europe Limited), in
order to decide whether to accept this proposal. I also understand that the Privacy Act 1993 entitles me to have access to and request the
correction of this information.
(e)
Although the signing of the declaration does not bind the Insurer or its agent to effect a Enrolled Learner Protection Bond, the Applicants
acknowledge that the particulars and statements contained in this proposal shall be the basis of the contract should a Enrolled Learner Protection
Bond be issued, and further the Applicants acknowledge that this proposal and declaration will be incorporated into the policy.
Name of Principal or Director
CBL Insurance Europe Limited is regulated by the Central Bank of Ireland
Company Registration Number: 218234
Signature of Principal or Director
Date
O’Driscoll O’Neil Limited is regulated by the Central Bank of Ireland
Company Registration Number: 249547
Copy additional pages as required
PLEASE PROVIDE A FULL LIST OF ALL COURSES INCLUDING COURSE TITLE, COURSE DURATION,
COURSE COST AND ANY OTHER RELEVANT INFORMATION PROVIDED BY YOUR SCHOOL
Course
Title
Course
Duration
Course
Cost
Max.
Places
QQI
Accredited
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Y
N
Intake
Dates
What is the date of incorporation of your school?
Please use the space below to provide a detailed background of your school. This should include the history of ownership,
material changes to the school and a summary of future plans.
CBL Insurance Europe Limited is regulated by the Central Bank of Ireland
Company Registration Number: 218234
O’Driscoll O’Neil Limited is regulated by the Central Bank of Ireland
Company Registration Number: 249547