Design and Construct Professional Indemnity Insurance Quote Form

Please insert your details below and one of our commercial advisers will contact you shortly with a professional indemnity insurance quote.

This form is designed for quotes for Design and Construct Professional Indemnity Insurance only.

If you have any problems with completing this form, please phone us on 01623 641 386 for assistance.

Personal/Company Details
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.
General Information
Occupation/Profession:
Description of your work undertaken: (Please describe as fully as possible including a percentage split between each activity, (where applicable))
Materials Facts
Is any asbestos or environmental work undertaken?	Yes     No
If yes, please provide details:
Are contracts or terms of engagement, including any changes, not evidenced in writing, specifying the work to be undertaken and the extent of your responsibility?	Yes     No
If yes, please provide reasons:
Do Governmental Departmental or Local Authority contracts exceed 50% of total income?	Yes     No
If yes, please provide details:
Have you or your company ever failed to complete a project?	Yes     No
If yes, please provide details:
If no design liability has been disclosed, have any past contracts been undertaken with a design liability?	Yes     No
If yes, please provide details: (i.e. details of contract, value of contract and when the contract was carried out)
You do not exclude indirect and consequential losses within your contracts with clients?	Yes     No
If yes, please provide details:
General Questions
Has any principal, partner or director of the company or organisation had any significant fluctuations in their income, or change in activities over the last 3 financial years, or are anticipated in the forthcoming 12 months?	Yes     No
If yes, please provide details:
Are contracts ever not drawn up in writing?	Yes     No
If yes, please provide details:
Has any disciplinary action previously ever been taken by an outside professional or regulatory body?	Yes     No
If yes, please provide details:
The principal, partner(s) or director(s) doesn't hold relevant qualifications or has less than two years relevant experience for the activities being insured?	Yes     No
If yes, please provide details:
The proposer has no established policy for checking the background of job candidates prior to them being offered the job?	Yes     No
If yes, please provide details:
Is cover required for any other previous business?	Yes     No
If yes, please provide details of previous business: (i.e. name of principal/partner involved, trading name of previous business, dates business operated to and from)
Proposer's 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:
Has any principal, partner or director of the business ever been previously declared bankrupt, insolvent or gone into liquidation, or ever had any CCJ's?	Yes     No
If yes, please provide details: (i.e. name of principal/partner involved, amount of bankruptcy/insolvency/CCJ (£'s), date of bankruptcy/insolvency/CCJ date of discharge of bankruptcy/isolvency/CCJ, etc.
Has any principal, partner or director of the business ever been convicted of, or charged for a criminal offence, or received a civil penalty from the UK Border Agency?	Yes     No
If yes, please provide details:
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)
Is the company registered at Companies House in the UK?	Yes    No
Number of Years Established
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
Claims Experience
Have you, or any other partner or director (past or present) suffered any claim (whether successful or not) in the last 5 years?	Yes     No
If yes, please provide details:	Date of claim: Cost of claim:£ Details of claim: ---------------------------- Date of claim: Cost of claim:£ Details of claim: ---------------------------- Regrettably, if you have more than 2 claims, we will be unable to provide you with a quotation.
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):
Percentage Split of Turnover Based on Design Work
Percentage of turnover where the firm carries out construction/installation based on designs drawn up by the firm?	%
Percentage of turnover where the firm carries out constrcution/installation based on designs drawn up by third parties appointed by the firm?	%
Percentage of turnover where the firm carries out construction/installation based on designs drawn up by third parties not appointed by the firm?	%
Percentage of fees for design only? (i.e. no construction element)	%
Percentage of fees for supervisory work only? (i.e. no design or construction element)	%
Percentage of all other turnover?	%
Total:	100%
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)
Design & Construct Activity Split
Percentage split of Design & Construct activities performed by your business:
Aborted work:	%
Architecture - New build/structural refurbishment:	%
Architecture - Non-structural refurbishment:	%
Building surveys non-structural / land surveys:	%
Civil engineering:	%
Electrical engineering:	%
Feasibility studies / expert witness work:	%
Heating and ventilation engineering:	%
Interior design:	%
Landscape / garden architecture:	%
Mechanical engineering:	%
Planning supervisory / CDM activities:	%
Project co-ordination:	%
Project management:	%
Quantity surveying:	%
Soil and foundation engineering:	%
Structural engineering:	%
Structural surveys / valuations:	%
Town planning:	%
Consulting:	%
Setting out:	%
Other (specify):	%
Total:	100%
Percentage Split of Facilities/Locations and Areas of Work
Percentage breakdown of facilities/locations and areas of work which your business undertakes:
Airports / railways:	%
All other leisure:	%
Amusement parks:	%
Arenas / stadia / amusement rides:	%
Aviation / automotive / military / marine:	%
Bridges / tunnels:	%
Chemical / oil / nuclear facilities:	%
Children's play areas:	%
Churches / cathedrals:	%
Cladding / glazing / curtain walling:	%
Clean rooms:	%
Dams / mines:	%
Demolition:	%
Factory / industrial:	%
Foundations / planning / underpinning:	%
Harbours / jetties / offshore installations:	%
Housing schemes / developments (over 3 floors):	%
Housing schemes / developments (under 3 floors):	%
Mechanical and bulk handling plant:	%
Office / retail:	%
Pipe work / tanks / vessels / silos:	%
Power plants:	%
Pubs / restaurants / hotels:	%
Roads / highways / motorways:	%
Schools / hospitals / municipal buildings:	%
Sewerage / water schemes:	%
Swimming pools:	%
Other (specify):	%
Total:	100%
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.
Details Of Current / Previous Policies
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.

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Disclosure
Please ensure that all the information you have provided is correct, then press the Request Professional Indemnity Quote button and we will contact you shortly with a quotation.

Estimated Quote Time: 1 to 72 hours