"Professional Indemnity Proposal Form - Pims-Sca" - United Kingdom

ADVERTISEMENT
ADVERTISEMENT

Download "Professional Indemnity Proposal Form - Pims-Sca" - United Kingdom

364 times
Rate (4.5 / 5) 22 votes
PROFESSIONAL INDEMNITY PROPOSAL FORM
Completion of this proposal form in no way binds the Proposer to purchase professional indemnity
insurance, nor does it bind Insurers to provide the required insurance.
1)
NAME:
ESTABLISHMENT DATE:
ADDRESS:
2)
Details of all Principals, Partners or Directors:
NAME
AGE
QUALIFICATIONS
1.
2.
3.
4.
3)
Breakdown of Company Turnover:
UK
USA/CANADA
OTHER
TOTAL
TOTAL TURNOVER IN LAST FINANCIAL YEAR
£
£
£
£
ESTIMATED GROSS FEES FOR NEXT FINANCIAL YEAR
£
£
£
£
LARGEST FEE FROM ANY ONE CLIENT
£
£
£
£
4)
Full Description of Activities, with percentage breakdown (estimated if no historical data):
%
%
%
%
PROFESSIONAL INDEMNITY PROPOSAL FORM
Completion of this proposal form in no way binds the Proposer to purchase professional indemnity
insurance, nor does it bind Insurers to provide the required insurance.
1)
NAME:
ESTABLISHMENT DATE:
ADDRESS:
2)
Details of all Principals, Partners or Directors:
NAME
AGE
QUALIFICATIONS
1.
2.
3.
4.
3)
Breakdown of Company Turnover:
UK
USA/CANADA
OTHER
TOTAL
TOTAL TURNOVER IN LAST FINANCIAL YEAR
£
£
£
£
ESTIMATED GROSS FEES FOR NEXT FINANCIAL YEAR
£
£
£
£
LARGEST FEE FROM ANY ONE CLIENT
£
£
£
£
4)
Full Description of Activities, with percentage breakdown (estimated if no historical data):
%
%
%
%
5)
Details of the three largest contracts in the last five years (give details of current projects if new business):
CLIENT
DESCRIPTION
CONTRACT VALUE
FEE
1.
2.
3.
6)
i) Have any claims in respect of the risks to which this form relates ever been
YES
NO
made against the business or any of the Principals, Partners or Directors?
ii) Are any Principals, Partners or Directors, AFTER FULL ENQUIRY aware of
YES
NO
any circumstance which might give rise to such claim?
iii) Has any proposal in respect of the risks to which this form relates ever been
YES
NO
declined or has any such insurance ever been cancelled or renewal refused?
If you have answered YES to any question, please provide details on a separate sheet.
Does the firm currently hold Professional Indemnity Insurance?
YES
NO
7)
i) Do you always have a written specification with your clients for each job
YES
NO
8)
which includes campaign details, volume, quality, timings and sign off procedures?
ii) Are all deviations to the above specification contract reported?
YES
NO
iii) Do you always obtain final client sign off before going to print?
YES
NO
If there is any other material information that you feel should be declared, please add on a separate
piece of paper.
I/we declare that, after full enquiry, the contents of this proposal 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 affected. If there is any material alteration to the facts and information which I/we have provided or
any new material matter arises before the completion of the contract of insurance, I/we undertake to
inform Insurers.
Signature of
Principal: _________________________________
Date:___________________________
V1/10/09
V2/10/09
Page of 2