Proposer's Full Name(s):(enter sole trader's name or all partners names if a partnership)
Contact Name:(if different to proposer's name)
Limited Company Name:(if operating as a limited company)
Trading Name:
Additional Trading Name(s) to be Insured:(if applicable)
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:
Please advise any professional memberships and/or qualifications relevant to your profession:(if applicable)
Description of your work undertaken: (Please describe as fully as possible including a percentage split between each activity , where applicable)
Do you anticipate any major changes in these activities in the forthcoming 12 months? Yes No
If yes, please provide details:
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
31 Years
32 Years
33 Years
34 Years
35 Years
36 Years
37 Years
38 Years
39 Years
40 Years
40+ Years
Previous Experience
Please can you confirm at least 50% of all directors, partners, principals and consultants are suitably qualified or have a least 3 years relevant experience? Yes No
If no, please provide details:
Can you confirm that you do not act as a self employed contractor for one employer? Yes No
If no, please provide details:
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:
Is cover required for any partners previous business? Yes No
If yes, please provide details of previous business:(i.e. name of partner, trading name of previous business, dates business operated to and from)
Has the firm previously undertaken any project in the USA or Canada? Yes No
If yes, please provide details:(please include type of project, dates to and from and size of the contract)
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
Are all companies to be covered under this insurance domiciled in the UK, Channel Islands or Isle of Man? Yes No
If no, please provide details:
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):
Largest Single Contract in Last 3 Years
Please confirm the total value of your largest fee earning contract undertaken in the last 3 years (£'s):(or an estimate if the first year of trading)
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
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
If there is any additional information to disclose or extra cover required, please provide details:
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 / Best Quote: This may help us to get you a better quote
Name of Current / Previous Insurer: e.g. Aviva, AXA, Allianz, QBE, RSA, Zurich, etc.