Proposer's Full Name(s):(enter sole trader's name or all partner's names if a partnership)
Contact Name:(if different to proposer's name)
Limited Company Name:(if operating as a limited company)
Trading Name:
Trading Status:
- - - - - - - Please Select - - - - - -
Sole Trader
Partnership
Limited Company (Ltd)
Limited Liability Partnership (LLP)
Public Limited Company (Plc)
Charity
Unincorporated Association
Business Address:
Postcode:
Daytime Telephone Number:
Mobile Telephone Number:
*E-Mail Address:
*Please note that your email address will only be used to provide you with your quote and not for any other marketing purposes.
Occupation / Profession:
Description of your work undertaken:(Please describe as fully as possible)
Trading Experience
How many years has your business been trading?
Please Select
0 Years
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
16 Years
17 Years
18 Years
19 Years
20 Years
21 Years
22 Years
23 Years
24 Years
25 Years
26 Years
27 Years
28 Years
29 Years
30 Years
30+ Years
Number of years experience (if different)
Please Select
0 Years
1 Year
2 Years
3 Years
4 Years
5 Years
6 Years
7 Years
8 Years
9 Years
10 Years
11 Years
12 Years
13 Years
14 Years
15 Years
16 Years
17 Years
18 Years
19 Years
20 Years
21 Years
22 Years
23 Years
24 Years
25 Years
26 Years
27 Years
28 Years
29 Years
30 Years
30+ Years
Proposer Details
Is all turnover derived solely from clients based in the United Kingdom? Yes No
Is the company a member of either the ICA, ACCA, CIMA, CIPFA, AAT, ICB, IFA or the ATT? Yes No
Can you confirm that the company is not connected or associated (financially) with any other business or concern, nor is it a member of a consortium, not has it entered into any joint ventures: Yes No
Can you confirm that the company does not undertake work in relation to: Insolvency, Liquidations and Receiverships, Mergers, Acquisitions and Disposals, Financial Services Work, and Audit and Accountancy work for Quoted Companies on the Stock Exchange? Yes No
Can you confirm that the company does not undertake work in the following area's:For Banks or other Financial Institutions, for Insurance Companies, Lloyd's Syndicates or Names, Lloyd's Managing or Members' Agents. For any Off-Shore Companies, or work on Off-Shore Funds / Investment Business as defined by the FSMA 2000 (and subsequent legislation), advise in respect of Split Capital Investment Trusts. Pension Transfers, OPT-OUT's, FSAVC's, SERPS', Low Cost Endowments, Income Draw Downs. Yes No
Can you confirm that the company does not undertake work for clients in the Entertainment Industry or Solicitors? Yes No
Can you confirm that the largest client's fee income is not over 50% of its Total Fee Income and does not exceed £100,000 in total? Yes No
If no, please provide details: (i.e. largest fee)
Proposer Details
Have you had any previous professional indemnity insurance declined, cancelled, renewal refused or any special terms imposed? Yes No
If yes, please provide details:
Are you aware of any fraud, dishonesty, bankruptcy or administration order applicable to any past or present principal, partner, director or employee? Yes No
If yes, please provide details:
During the past 6 years has the business name been changed, have any other businesses been purchased, or has any merger or consolidation taken place? Yes No
If yes, please provide details:
Claims Experience
Have you, or any other partner or director (past or present) suffered any claim (whether successful or not) in the last 10 years? Yes No
If yes, please provide details:
Are you, or any other partner or director aware of any circumstances after investigation which might give rise to a claim? Yes No
If yes, please provide details:
Staff
Number of Proprietors/Partners/Co. Directors:
Number of Employees:(Do not include proprietors, partners or directors)
Turnover
Annual Gross Fees / Turnover (UK) (£'s):
Annual Gross Fees / Turnover (EU) (£'s):
Annual Gross Fees / Turnover (USA/Canada) (£'s):
Annual Gross Fees / Turnover (Rest of World) (£'s):
Sub-Consultants
What percentage of turnover do you pay to outside or sub-consultants or third parties? %
If fees are paid to outside or sub-consultants, are they engaged in a binding contract accepting responsibility for their own neglect, error or omission for the work they undertake? Yes No
Professional Indemnity Cover Required
Limit of Indemnity required:
Please Select
£100,000
£250,000
£500,000
£1,000,000
£2,000,000
£3,000,000
£5,000,000
£10,000,000
Does your company currently have professional indemnity insurance? Yes No
Do you currently have a retroactive date for your current policy? Yes No
If yes, please provide the retroactive date of your current policy: (dd/mm/yyyy)
Additional Information
Any additional information you wish to disclose or additional cover required:
You are required to make a fair presentation of the risk to insurers which means that you are required to disclose every material circumstance which you know or ought to know relating to the risk to be insured. Materially important information is any information that could influence an insurer's decision to accept your risk including the cost of your insurance. Failure to comply with the duty of fair presentation could mean that your policy is void or that insurers are not liable to pay all or part of your claim(s). By submitting this quotation you are confirming that there are no other material facts to disclose other than those shown above.
Renewal Date / Cover Start Date: (dd/mm/yyyy)
Current Annual Premium: This may help us to get you a better quote
Name of Current / Previous Insurer: e.g. Aviva, AXA, Allianz, QBE, RSA, Zurich, etc.