Professional Indemnity Insurance Policy Proposal Form

Proposer's Name*

Phone*

Email*

Address*

Trade/Business Type

Date of Establishment

Please provide the following details of all Partners/Directors/Principals:

Is coverage required in respect of past work for any Partner/Principal who has left, retired or died? YesNo

If ‘YES’ please give the following:

Please state the following:

No. of qualified Engineers

No. of Draughtsmen

No. of Administrative Personnel

Specify nature of supervision exercised over the employees

Total amount of annual Wages payable

Please state the 5 largest contracts where construction has commenced during the past 6 years

Please give details of Contracts where construction is expected to commence in the next 12 months

State whether you undertake Supervision of Contract works being executed? YesNo

If Yes, periodicity of inspection with details:

Do you engage persons outside your organization? YesNo

If yes, specify the details of purpose and nature of control exercised by you over them

Loss Record for 5 years

Have you during the past 12 months dismissed or do you contemplate dismissal of any member of staff on account of any omission, neglect, error or such like? YesNo

If Yes, please give full details

Are you aware of any neglect, omission or error or existence of any circumstances likely to give rise to a claim? YesNo

If Yes, please give full details

Please give gross fees received during the past five years

Estimated fees for the coming 12 months

Has any company declined your proposal? YesNo

Has any company required an increased premium? YesNo

Has any company refused to renew your policy?YesNo

Has any company cancelled such a policy? YesNo

Professional Indemnity Insurance Policy Proposal Form