Form Application for Professional Indemnity


Professional Indemnity proposal form

Company Name:

Address Line 1:

Address Line 2:

Email:

VAT Number:

Telephone Number:

Fax:

Insurance broker to whom quotation should be sent:

1 General Information

a. Date established:

b. Name and Address of any subsidiary, affiliated, associated companies or branch offices which you wish to cover:

Name and Address Main Activity

c. Number of Directors/Partners:

Total number of staff:

d. Names, positions, professional qualifications and number of years experience of Directors/Partners and Senior Managers

Director, Partner, Principal 1

Name:

Qualifications:

Year Obtained:

Length of time as Director, Partner, or Principal:

Director, Partner, Principal 2

Name:

Qualifications:

Year Obtained:

Length of time as Director, Partner, or Principal:

Director, Partner, Principal 3

Name:

Qualifications:

Year Obtained:

Length of time as Director, Partner, or Principal:

Director, Partner, Principal 4

Name:

Qualifications:

Year Obtained:

Length of time as Director, Partner, or Principal:

Please provide copies of relevant curriculum vitaes with brochures/literature relating to your company.

Additional File 1:

Additional File 2:

Additional File 3:

e. Name of person to whom correspondence should be addressed:

2 Business activities

a. Please briefly describe the nature of your business:

b. Please indicate your approximate gross income/fees. Please state currency, e.g., US$

i. Last financial year:

ii. This financial year:

iii. This financial year:

iv. Of which estimated income from UK operations (if applicable):

c. Please name the principals for whom you regularly act:

d. Are you involved in the manufacture, construction, alteration, repair or sale of products other than in a consultancy capacity?

If "Yes", please supply details:

e. Do you enter into any written agreement or operate under a standard form of contract?

If "Yes", please supply copies

Additional File 1:

Additional File 2:

Additional File 3:

f. Are you a member of any trade association?

If "Yes", please details:

5 Insurance/Claims History

a. Are you currently insured against the risks covered by ITIC?

If "Yes": (if "No", please give details of most recent insurance)

i. Name of insurer?

ii. Limit of indemnity?

iii. Excess/Deductible:

iv. Premium:

v. Expiry date:

b. Has any insurer

i. Declined to insure you?

ii. Cancelled your insurance?

iii. Refused to renew your insurance?

iv. Imposed penalties or special terms?

If "Yes", please attach details using the extra file attachments at the bottom

c. Have any claims for professional negligence, successful or not, ever been made against your company or its present Directors?

If "Yes", please attach details using the extra file attachments at the bottom

6 Limits and Deductibles

Please indicate any preferred limits or deductibles

Alternative 1 Limit: Deductible: Currency:
Alternative 2 Limit: Deductible: Currency:

7 Quality Assurance

Have you obtained quality assurance accreditation in accordance with BS5750/ISO9002?

8 Please attach any relevant additional files below

Additional documentation 1:

Additional documentation 2:

Additional documentation 3:

Additional documentation 4:

Additional documentation 4:

Additional documentation 4:

DECLARATION

I/We undertake that if this proposal is accepted I/We will act and abide and agree to be bound by the Rules of the Company and any modification or alteration thereof made in accordance therewith from time to time by the decision of the Company.

I/We declare that to the best of my/our knowledge and belief, the information given above is true and that I/We have not suppressed or misstated any material facts. (A material fact is one likely to influence the underwriter’s assessment of this proposal).

Signed:

(By typing your name, you are officially signing this form)

Status of Signatory:

Date:

This proposal form must be completed and signed by a person who is authorised to bind the proposer.