Information Technology Consultants Proposal Form

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1 Proposal Form This Proposal form must be completed in ink, signed and dated by a Principal, Partner or Director of the Proposer. All questions must be answered and where appropriate not applicable or n/a specified. The completed proposal form along with all additional information provided will form part of the contract of insurance with the Underwriters. All facts material to the proposed insurance must be disclosed fully and truthfully and to the best of the Proposer s knowledge and belief whether or not they are subject of a specific question herein. In addition to the information contained in the proposal form including all supporting documentation, if the Proposer is aware of any other information which it considers may alter, influence or prejudice the Underwriters appraisal of the risk being proposed, this information must be disclosed in conjunction with this proposal form. It is agreed by the Proposer that any information provided to the Underwriters will be processed by the Underwriters in compliance with the provisions of the Data Protection Act 1998, which may necessitate providing such information to third parties. By signing this proposal form the Proposer is consenting to the use of information, including sensitive personal information. Where personal information relates to third parties, the Proposer confirms that it has been given the requisite consent to disclose such information to the Underwriters for processing. If there is insufficient space to complete an answer to any question in this proposal form, please continue on a separate company headed paper which should be signed, dated and attached to this proposal form. Proposer means the firm or company proposing for this insurance.

2 The Firm 1. Name(s) of Proposer(s) (including any subsidiaries and previous firms to be included under this insurance): Name Date established 2. Main Postal Address: Postcode: 3. All other branch addresses: 4. Partner(s)/Director(s)/ Principal(s): Full Name Qualifications Date Qualified Length of service with proposer 5. Total Number of Staff: Partners/Directors/Principals Qualified Staff (not mentioned above) Others (administration) Self Employed/Contract Hire Total Number of Staff 6. In the past 10 years, has the Proposer changed its name, been part of an amalgamation or merger, de-merger or in any way had a material change to its activities? 7. Has any principal, partner, director of the Proposer s business been made personally bankrupt, or been personally associated with any business which has been placed into receivership, liquidation, or been wound up? 8. Has any partner, principal, director or employee of the Proposer been the subject of professional disciplinary proceedings or committed a fraudulent or dishonest act? 9. Is the Proposer a current member of any Professional Association or Institute?

3 If you have answered YES to questions 6 to 9 please provide full details: 10. Is the business of the Proposer a part-time occupation? If YES please provide details of full-time occupation: 11. If the Proposer is a Sole practitioner what procedures are in place for periods of absence from the office due to holiday leave or sickness?: Income 12. Total gross fee income for the last three financial years and estimate for forthcoming financial year ( s): Financial Year End date (dd/mm/yy) UK EU (non UK) USA/Canada Elsewhere Total Sub 13. Does the Proposer use the services of specialist designers/engineers/consultants or sub consultants? Consultants a) If YES what percentage of the last completed financial year s income was paid to sub contractors and what work do they perform on your behalf? Paid Services performed Minimum level of professional indemnity required % % % b) Do you contractually require and have formal management systems to ensure that all specialist designers/engineers/consultants or sub contractors appointed maintain their own professional indemnity insurance for the duration of their liability? If No please advice reason why sub consultants are not required to maintain their own Professional Indemnity Insurance:

4 Contract Details 14. Please provide details of the 5 largest projects/contracts commenced during the last 5 years: Client Services Performed Total Contract Value Firm s Contract Value Firm s Fee Start Date Completion Date 15. Please provide details of the 3 largest projects/contracts due to commence in the next financial year: Client Services Performed Total Contract Value Firm s Contract Value Firm s Fee Start Date Completion Date 16. If fee income from outside of the UK, please provide details: Country/State/Province Services Performed Size of Contract Fee Income 17. Does the Proposer enter into contracts with clients under any jurisdiction other than the laws of England and Wales?

5 Activities 18. Please indicate as a percentage which of the following client groups to whom you have provided advice or consultancy during the last completed financial year (%): Chemical/process Industry % Pharmaceutical % Defence % Power Industry % Financial Services % Railway % Medical % Water Industry % Nuclear % Others (Please state) % Oil, Gas & Petrochemical Industry % 19. In respect of the following please indicate the approximate percentage split for each category (%): Shrink-wrapped software Your Own Products % Third Party Products including related consultancy % Pure Third Party Product sales % Customisable sales % Project based work (including any related consultancy, maintenance and hardware sales) 100% custom software development % Maintenance % Mixed shrink-wrapped software/custom solutions % Installation % Mixed hardware/software solutions % Service Provision Project Management % Provision of Managed Services % Facilities Management % General Business Consultancy % Contract Programming % Quality Assurance % Data Processing % Training % Provision of Temporary Staff % System Audit % Provision of Outsourced Services % Hardware Sales of own Brand % Installation % Distribution of other brands % Maintenance % Website Design % Hosting % Maintenance % Domain Name Registration % Others - please specify:

6 20. If undertaking work for Financial Institutions does this work involve dealing/live trading systems? 21. Is the failure of any of the Proposer activities or services liable to result in any of the following outcomes? a) Loss of life or injury to a person? b) Destruction or damage to physical property? c) Immediate and large financial loss? d) Insignificant financial loss (more of a nuisance)? 22. Does the Proposer anticipate any material changes to its activities in the forthcoming 12 months? Joint 23. Does the Proposer carry out work as a member of a Joint Venture or Consortium? Ventures If YES please complete addendum to this proposal form. Financial 24. Does the Proposer or any partners/principals have a financial interest in any other business entity? Associations Risk 25. Do you use your own standard contract terms and conditions? Management If YES please provide a copy if NO please complete Q What percentage of your contracts are carried out using your own standard terms and condition? % 27. Do your contract terms and conditions include any of the following? a) Limitation of your liability in respect of consequential loss b) Exclusion of Warranties and Guarantees c) Hold Harmless agreements d) Limitation of your liability to a multiple of fee If yes to d) is the multiple: Times three or less Four times or greater 28. If you do not use standard contract terms and conditions please clarify how liability is limited for the products and/or services provided:

7 29. Does the Proposer carry out regular project reviews? 30. Does the Proposer retain written record of telephone conversations and attendance at meetings? 31. Does the Proposer always obtain satisfactory written references, immediately preceding the engagement of any partner, director, member or employee? 32. Does the Proposer obtain satisfactory written references, accounts and proof of insurance when nominating a contractor for tendering? 33. Are all working papers, records or documents relating to the business activities of the firm (or predecessors in business as stated in answer to question 1) kept in a secure and accessible location? If No please explain why: Professional Indemnity 34. What Limit of Indemnity does the Proposer require? Insurance 250, ,000 1,000,000 2,000,000 5,000,000 Other 35. What Excess is the Proposer prepared to carry? 1,000 2,500 5,000 10,000 25,000 Other 36. Has the Applicant ever been refused this type of insurance, had special terms imposed by Insurers or had a similar insurance cancelled? 37. Does the Proposer currently hold a Professional Indemnity policy? If YES please complete the following Insurer Limit of Indemnity Excess Premium Renewal Date

8 Claims 38. Please provide answers to the following questions. Due to the Claims Made basis of Professional Indemnity please give them very careful consideration. Failure to answer them correctly could prejudice the (Proposer s) rights under any insurance contract effected with Underwriters. a) During the past 10 years have any claims been made against the Firm, any Partner/Director, or their predecessors in business in respect of liabilities covered by the proposed Professional Indemnity insurance? b) Are any of the Partners/Directors AFTER FULL ENQUIRY within the firm aware of any circumstances which may give rise to a claim against the Firm, their predecessors in business or any former Partner/Director? c) Have you suffered any loss from fraud, dishonesty or malice? Do you currently have any grounds for suspecting that you may suffer loss through fraud, dishonesty or malice? d) Have any claims been made against the Proposer or any director, partner or senior member of the staff while in a previous firm? If YES to any of the above please provide full details, including the amounts involved: Incident Date Details of Claim/Circumstance Amount Claimed Insurer Reserve/Paid Defence Costs Excess Closed (Y/N) Declaration I/WE DECLARE THAT AFTER FULL ENQUIRY OF ALL THE DIRECTORS/PARTNERS/PRINICIPALS, MANAGERS, AND EMPLOYEES, THE STATEMENTS AND PARTICULARS CONTAINED IN THIS PROPOSAL FORM(S) ARE TRUE, COMPLETE AND REMAIN ACCURATE IN ALL RESPECTS AND THAT I/WE HAVE NOT OMITTED, SUPPRESSED OR MISSTATED ANY MATERIAL FACTS. I/WE AGREE THAT THIS PROPOSAL, TOGETHER WITH ANY OTHER INFORMATION SUPPLIED BY ME/US SHALL FORM THE BASIS OF ANY CONTRACT OF INSURANCE EFFECTED THEREON. I/WE UNDERTAKE TO INFORM INSURERS OF ANY MATERIAL ALTERATION TO THESE FACTS OCCURING BEFORE COMPLETION OF THE CONTRACT OF INSURANCE. COMPLETION AND SIGNATURE OF THIS PROPOSAL FORM DOES NOT BIND THE PROPOSER OR THE INSURERS TO COMPLETE A CONTRACT OF INSURANCE. COMPANY NAME: SIGNATURE OF PROPOSER (DIRECTOR/PARTNER/PRINCIPAL): DATE (dd/mm/yy): A COPY OF THIS PROPOSAL FORM SHOULD BE RETAINED FOR YOUR OWN RECORDS

9 Joint Ventures Addendum Please complete this addendum if any income emanates from work while a member of a Joint Venture or Consortium

10 1. Please complete the following information: JV Partner Project Details Contract Period Work Undertaken Proposer Income Total JV Income 2. Are procedures in place to ensure that any Joint Venture partner is of adequate financial standing and expertise to fulfil its obligations under any contract entered into on a joint venture basis? If NO please provide details 3. Does the Proposer ensure that it is not legally liable for negligent acts, errors or omissions of any other Joint Venture partners? If NO please provide details 4. Does the overall Joint Venture entity purchase a separate Professional Indemnity Insurance policy to protect all partners within the Joint Venture? Please provide details

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