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 Professional Indemnity Insurance only. Professional Indemnity Insurance is designed for professionals who require cover for their legal liability in the event of any incorrect advice, error or ommission which causes financial loss to their clients.

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:
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:	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
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.
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