professional indemnity insurance

Please complete all the mandatory fields marked with an *
* Title
* First Name
* Surname
* Address
* Telephone
Mobile
* Email
Method Of Contact

Company Name
Company Registration Number
Business Description
Date Established:

Fax Number
Professional activities of Proposer
Professional Associations
Associated Interests:
Please give details of any Director or Partner of the Proposer financially associated with any other firm
History:
Please give details of any mergers, aquisitions, consolidations or name changes which have occurred during the past 5 years
N.B. If cover is required for any firm(s) detailed in answer to question 7, please ensure that they are correctly identified in your answer to question 1
Human Resources:
Full names of all Directors/Partners
Number of years in this Capacity
Qualifications
Date Qualified:
Please provide details/curriculum vitae of any Director/Partner with less than 5 years applicable experience
If sole Director/Partner, is this a part time occupation? If so, please provide details of other occupations
Details of Professionally Qualified Staff:
Name
Title and length of time as such
Qualification
Date Qualified:
If unqualified staff are executing activities/details normally undertaken by qualified persons
Name
Title
Activities/Duties
Length of Time undertaking such Activities/Duties
Total number of staff
Financial Analysis
Please give total Gross fees for the past 3 competed years
Year end
United Kingdom
USA/Canada
Other
Total
Year end
United Kingdom
USA/Canada
Other
Total
Year end
United Kingdom
USA/Canada
Other
Total
Estimate for forthcoming year	£
Largest total fee from any one client	£
Average Fee	£
Please give a brief description of your activities and the relevant percentage of income below
Description of activities
% of income
Additional Information
Please give details of the 3 largest jobs performed by the proposer
Job 1
Type of Contract
Territory
Job 2
Type of Contract
Territory
Job 3
Type of Contract
Territory
Are all of your contracts subject to law	Yes No
If NO please give details
Are full rights of recourse maintained against sub-contractors, consultants and product suppliers	Yes No
If NO, please explain
Please give details of any substantial changes to the Proposer's activities during the next 12 months
Is coverage required in respect of any Director/Partner who has left, retired or died	Yes No
If NO, please give details
Full names of all Directors/Partners
Number of years in this Capacity
Qualifications
Date Qualified:
Please provide details/curriculum vitae of any Director/Partner with less than 5 years applicable experience
If sole Director/Partner, is this a part time occupation? If so, please provide details of other occupations
Is coverage required for any Director/Partner for liabilities arising out of a previous business	Yes No
If YES, please drovide details
Is coverage required for:
Loss Of Documents	Yes No
Dishonesty of Employees	Yes No
Libel & Slander	Yes No
Infringement of Copyright	Yes No
Details of existing Insurance
Does the Proposer currently buy Professional Indemnity Insurance	Yes No
If yes:
Name of existing Insurer
Indemnity Limit	£
Self Insured Excess	£
Premium	£
Renewal Date:
Retroactive Date:
Has any proposal for Professional Indemnity Insurance been made on behalf of the Proposer, Present Director/Partner or any predecessors in business ever been declined or punitive conditions imposed?	Yes No
If Yes please give details
Limits required:
Please state the Limit(s) of Indemnity for which you require quotations:
£
£
£
£
Please state the amount of Self Insured Excess you are prepared to carry. Please note, a minimum Self Insured Excess will be required based on the answers contained in this proposal form:
£
£
£
£
Claims Experience:
Please note that Professional Indemnity Insurance is on a 'claims made' basis and Insurers will exclude any claim, circumstance which may/or is likely to give rise to a claim known by the Proposer prior to the inception of any Professional Indemnity policy. In order that your interests are fully protected you must answer the following questions after full enquiry.
Have any Professional Indemnity claims been made against the Proposer or any former Director/Partner including whilst acting at any other firm during the last 10 years?	Yes No
If Yes please give details
Are any of the Directors?partners or employees, AFTER FULL INQUIRY aware of any circumstance which may give rise to a claim against the proposer or their predecessors in business or any of the present or former Directors/Partners	Yes No
If Yes please give details
To the best of my knowledge I believe the information given to be true and correct.