HOULDER INSURANCE SERVICES

Transcription

1 HOULDER INSURANCE SERVICES PROFESSIONAL INDEMNITY PROPOSAL FORM ENGINEERS

2 PLEASE READ THE FOLLOWING BEFORE COMPLETING THIS PROPOSAL FORM: ALL QUESTIONS SHOULD BE COMPLETED IN INK. WHERE A QUESTION IS NOT APPLICABLE TO YOUR PARTICULAR CIRCUMSTANCES, PLEASE WRITE N/A. PLEASE TICK THE YES OR NO BOXES. IF THERE IS INSUFFICIENT SPACE TO ANSWER QUESTIONS PLEASE USE AN ADDITIONAL SHEET AND ATTACH IT TO THIS PROPOSAL FORM. COMPLETING AND SIGNING THIS PROPOSAL FORM DOES NOT BIND THE PROPOSER OR INSURERS TO COMPLETE THIS INSURANCE. IF THIS PROPOSAL RELATES TO A NEW BUSINESS OR VENTURE, PLEASE COMPLETE THE QUESTIONS AS FAR AS POSSIBLE, GIVING ESTIMATED OR ANTICIPATED INFORMATION. PPLENG 2

3 SECTION (1): DETAILS OF PROPOSER 1 Name of Individual or Firm requiring cover: 2 a) Principal address: Post Code: b) If other locations please specify town/city only: 3 Date established: 4 Please provide details of all Partners, Principals and Directors: Length of time Name Qualifications Date Qualified Age position held Please attach a CV for any unqualified Partner, Principal or Director PPLENG 3

4 SECTION (2): DETAILS ABOUT YOUR BUSINESS 1 Please advise the total number of: a) Partners, Principals or Directors b) Qualified Staff c) All other staff 2 If you are a sole Practitioner please advise: a) Details of your full time occupation (if any) b) What arrangements are in place in the event of sickness or holidays to ensure continuance of the business? 3 a) Do you engage consultants or sub-contractors? YES NO If YES please give details of the nature of activities undertaken by such consultants or sub-contractors b) Do you check that the consultant or sub-contractor: i) has appropriate qualifications? YES NO ii) maintains Professional Indemnity insurance? YES NO 4 Please give details of membership of any Association or Professional Body 5 Do you use standard Contract Conditions/Letter of Appointment YES NO If YES please attach a copy If NO please provide details of how you define your duties to your client: PPLENG 4

5 6 Is work undertaken for any entity in which any Partner, Principal or Director of the Proposer is able to exercise a controlling interest? YES NO If YES please give full details and income derived from this source: 7 Are you associated financially or otherwise with any other entity? YES NO If YES please give full details:- 8 Are you a member of a Consortium or Joint Venture? YES NO If cover is required in respect of your own liability as a member of the Consortium please provide the following:- a) Name of Consortium b) Type of services being provided c) Annual income/fees received from the Consortium 9 a) Please confirm the gross fees for the last 2 completed financial years and estimates for the current and forthcoming years: Year End Gross Fees U.K Overseas (excl. USA/Canada) % % % % % % % % b) Please confirm the largest fee derived from any one entity: c) Please advise the average fee earned per entity: d) Please advise fees paid to consultants/sub-contractors: PPLENG 5

6 10 Please confirm the approximate division of each discipline undertaken during the last complete financial year: Civil % Electrical % Structural % Architectural % Soil % Town Planning % Mechanical % Structural Surveys/Valuations/Inspection Reports % Heating and Ventilation % Other Work % (please give details below) 11 Please confirm the approximate division of each activity undertaken during the last complete financial year: Bridges/Flyovers/Tunnels/Dams/Mines % Hospitals/Universities/Schools % Harbours/Jetties/Sea Defences % Housing % Chemical/Petrochemical/Refineries % Factories/Offices/Retail % Nuclear/Atomic Projects % Mechanical Plant % Water/Sewerage Schemes % Others % (please gi ve details below) PPLENG 6

7 12 Please provide details of the 3 largest contracts undertaken in the last 3 years: i) Client Fee earned Total Contract Date Date Value Commenced Finished ii) iii) 13 a) Have any major changes to your activities or structure taken place in the past 2 years? YES NO If YES please provide details: b) Are any major changes expected to your activities or structure in the next year? YES NO If YES please provide details: c) Have you carried out any activities other than those disclosed in this Proposal? YES NO If YES please provide details: PPLENG 7

8 SECTION (3): YOUR P.I. REQUIREMENTS 1 Have you previously been insured or currently have Professional Indemnity Insurance in force? YES NO If YES please advise: a) Name of Insurers b) Renewal date c) Limit of indemnity d) Excess e) The number of consecutive years you have been insured 2 What Limit of Indemnity do you require? 250, ,000 1,000,000 Other (please specify amount): PPLENG 8

9 SECTION (4): PREVIOUS INSURANCE & CLAIMS HISTORY 1 In respect of the Proposer or any Partner, Principal or Director has any Insurer ever cancelled, YES NO declined to provide or renew any Professional Indemnity Insurance or imposed special terms? If YES please give details: 2 Has any Partner, Principal, Director or Employee been subject to disciplinary proceedings by YES NO any Association or Professional Body? If YES please give details: 3 a) Has any claim, whether successful or not ever been made against the Proposer or its YES NO predecessors in business or any past or present Partner, Principal, Director or Employee? If YES please give details of dates, amount claimed, allegations and current position PLEASE NOTE: If any Partner, Principal, Director or Employee is aware of any claim relating to activities carried out by them in previous practice or employment, details should be disclosed under this question. b) Are you or your Partner, Principal, Director or Employee AFTER FULL ENQUIRY aware YES NO of any circumstance or any circumstances which may give rise to a claim against the proposer, its predecessors in business or any past or present Partner, Principal, Director or Employee? If YES please give full details: I/We declare that the statements and particulars given in this Proposal are correct and that no material fact has been omitted. I/We agree that this Proposal together with any other information supplied shall form the basis of the contract. Signature Position Date PLEASE NOTE: It is necessary for you to disclose all Material Facts which may influence us in acceptance or assessment of this Proposal. Failure to do so could invalidate this insurance. If you are in doubt whether any fact is material you should disclose it. PPLENG 9