PROFESSIONAL INDEMNITY – PROPOSAL

The completion of this form in no way binds the Proposer to purchase insurance, nor does it bind the Underwriters to give insurance. Any information given will only be passed to Underwriters for the purpose of quotation and will be treated as confidential.

Proposer details
Proposer Name / Business Name: (this is the ‘insured’ name to appear on the policy)	Contact name:
Address:	Postcode:
Telephone:	Mobile:
Email:	Establishment date:

Full description of business activities
Percentage breakdown of the above activities or estimates if new start-up
%	%
%	%
%	%

Cover
Limit of indemnity required:	£
Does the firm currently hold professional indemnity insurance?
If the firm does currently hold PI insurance please answer the following, otherwise move to the next section
Current insurers:
Current broker:
Renewal date:
Retroactive date:
Premium:	£
Excess:	£

Principals, Partners or Directors
Name	Age	Qualifications

Fees
UK	EU	USA/Canada	Rest of World	Total
Total gross fees in last financial year:	£	£	£	£	£
Estimated gross fees for next financial year:	£	£	£	£	£
Largest fee from any one client:	£	£	£	£	£
Are all overseas contracts subject to UK law?	YES	NO	N/A	If NO please provide details

Details of the 3 largest contracts in the last 5 financial years (details of current projects if new business):
Client	Description	Contract Value	Fee
1	£	£
2	£	£
3	£	£

Claims / circumstances
Have any claims in respect of the risks to which this form relates ever been made against the business or any of the Principals, Partners or Directors?
Are any of the Principals, Partners or Directors AFTER FULL ENQUIRY aware of any circumstances which might give rise to such a claim?
Has any proposal in respect of the risks to which this form relates ever been declined or has any such insurance ever been cancelled or renewal refused?

If YES to any questions above, please provide details on a separate sheet.

Other material information

Declaration

CV’s of Directors/Partners/Principals are always useful; please supply these wherever possible with this form.

I/We declare that, after full enquiry, the contents of this proposal form are true and that I/We have not misstated, omitted or suppressed any material fact or information. I/We agree that this proposal together with any other information supplied by me/us shall form the basis of any contract of insurance which may be effected. If there is any material alteration to the facts and information which I/We have provided or any new material matter arises before completion of the contract of insurance, I/We undertake to inform Underwriters.

Signature of Principal:	Date: