Octagon House, 18 Nash Green, Hemel Hempstead, Herts. HP3 8AA        Phone :   01442 242 400
Professional Indemnity
 
Name:
Email :
Postcode :
Phone No :
Company Name :
Correspondence address :
Are you a Member of a Trade Organisation :
Yes: No
Current professional indemnity insurer :
Policy expiry date:   
Retroactive Date :   
Excess :
Premium :
Please select the limit of indemnity you require £250k £500k £1 Million £2 Million £5 Million
Claims
Are you aware of any claim being brought against you arising out of the performance of your business activities or has anyone ever threatened to bring such a claim (please clearly circle your response)?
Yes: No
Are you aware of any circumstance(s), which may lead to a claim against you in the future (including any complaints or criticisms of your activities (please clearly circle your response)?
Yes: No
Have you suffered any loss from fraud, dishonesty or malice or do you have any grounds for suspecting that you may suffer loss through fraud, dishonesty or malice (please clearly circle your response)?
Yes: No
Are there any other details or is there any other information relating to claims, circumstances, or complaints, which you believe may be relevant to the consideration of this proposal for insurance (please clearly circle your response and include details on a separate sheet)?
Yes: No
Does your firm engage sub contractors/ Do you check their insurance cover to ensure they have a minimum level of cover
 
Yes: No
Please provide the following information:
Names of all partners, directors or members (include your own details if you are a sole practitioner
Commenced employment on :
Professional qualifications :
Date qualified :   
Fee Income
Provide details of your gross fees over the last three financial years and an estimate of your expected fees for the year to come.
    Last complete year  Current /
Future Year (Est.)
Republic of Ireland & UK £
Total Fees £
Please complete the table below, giving the percentage split, per project type, of the total fees earned by your firm during the last complete financial year.
Residential : %  
Commercial : %  
Other :Details : %  
Please provide details of your three largest contracts undertaken in the last five years:
Date(s) Client name Total contract value Your fees Your role in the contract
Please provide details if possible of the three largest contracts you are due to undertake in the forthcoming year:
Date(s) Client name Total contract value Your fees Your role in the contract
Surveyors Only
Largest single valuation: (Surveyors Only)
Average single valuation: (Surveyors Only)
Have you ever undertaken any work outside Ireland or the UK
Yes: No
Declaration

I/We declare that this proposal form has completed after proper enquiries of all Partners, Principals and Directors, and that the contents are true and accurate and that all facts and matters, which may be relevant for consideration of our proposal for insurance, have been disclosed.
I/We undertake to inform insurers before any contract of insurance is concluded of any material change to the information already provided or any new fact or matter, which may be relevant to the consideration of the proposal for insurance, that comes to light.
That this proposal form and all other written information is provided will be incorporated into and form the basis of any contract of insurance, should one be concluded.
I Agree I Disagree
Additional Information/Comments