Contractors Choice. Professional Indemnity Supplementary Proposal Form September 2013 Edition

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1 Contractors Choice Professional Indemnity Supplementary Proposal Form September 2013 Edition

2 Proposal for Professional Indemnity Insurance (Building Contractors Design and Construct) This product is only available in conjunction with a Contractors Choice Policy Important Notice To apply for this extension to the Contractors Choice Insurance Policy, complete this Proposal Form in BLOCK CAPITALS using a ball-point pen (blue or black ink).you must complete all parts of this Proposal Form in all cases. Insurance begins when AXA Insurance has accepted your application. You must give full and true answers to all questions. If you do not do so your insurance cover may not protect you in the event of a claim. You should keep a record of all information supplied to AXA Insurance (including copies of correspondence). If the space provided is inadequate please supply full details using the Additional Information Section. A copy of this Proposal can be supplied on request, within a period of 3 months after its completion. A copy of the Policy is available on request. AXA Insurance UK plc is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Law Applicable to Contract You and we can choose the law which applies to this Policy. We propose that the Law of England and Wales apply. Unless we and you agree otherwise, the Law of England and Wales will apply to this Policy. PART A Your Business Details 1 Full Title of Proposer and Subsidiary Companies to be included in this insurance 2 Postal Address Postcode 3 Telephone number 4 Period of Insurance from 5 Do you wish pay the premium by instalments? If Yes please complete a Budget Plan Application to 6 a) When established b) State name and business of any company or practice with which you are financially associated, other than those stated in 1 above 2

3 7 a) Please give a general description of the type of professional activities undertaken b) Do you endeavour to limit your liability with the principal/employer under contract? If yes please provide details: c) Do you engage the services of or assume responsibility for independent sub-consultants or sub-contractors If Yes : i) Please state which design and professional activities are sub-contracted to other professional firms ii) Do you ensure that such sub-consultants or sub-contractors have professional indemnity insurance for not less than the amount of cover requested by this Proposal? d) Do you undertake the duties of Planning Supervisor under the Construction (Design and Management) Regulations 1994? If Yes : Please give name and details of the training undertaken by those persons involved with planning supervision duties in health and safety and length of experience 8 a) Is there any major change in the nature of activities anticipated in the next 12 months? If Yes please provide details: b) Have you used or are you intending to use any prototype or innovation construction techniques, designs or materials? If Yes please provide details: 9 Please state total turnover for the last 3 years: (YYYY) (YYYY) (YYYY) 3

4 10 Please give an estimate of turnover for the next 12 months for: a) Contract values where you are responsible for the design and construction i) own design and full technical supervision* ii) own design and technical services but construction work sub-contracted in the main iii) construction from others designs, own technical supervision iv) construction but design and technical supervision sub-contracted to outside professionals b) Contract values where you have no responsibility for design (no professional indemnity cover required) Please give an estimate for the next 12 months of: c) Fees received for design only contracts, reports and feasibility studies d) Fees received for contracts where your responsibilities are solely those of a Planning Supervisor under the CONDAM Regulations Estimated Total (a, b, c and d) *THE TERM TECHNICAL SUPERVISION IS NOT INTENDED TO EXTEND TO THE SUPERVISORY ACTIVITIES WHICH UNDER A TRADITIONAL FORM OF CONTRACT WOULD BE THE RESPONSIBILITY OF THE CONTRACTOR, AND NOT THE PROFESSIONAL TEAM. 11 Please state the 5 largest contracts where construction began during the past 5 years and where professional services have been provided: Starting Date Country Type of Contract (Hotel, Factory, etc.) Total Contract Value Firms Contract Value Approx. Completion Date Starting Date Country Type of Contract (Hotel, Factory, etc.) Total Contract Value Firms Contract Value Approx. Completion Date Starting Date Country Type of Contract (Hotel, Factory, etc.) Total Contract Value Firms Contract Value 4 Approx. Completion Date

5 Starting Date Country Type of Contract (Hotel, Factory, etc.) Total Contract Value Firms Contract Value Approx. Completion Date Starting Date Country Type of Contract (Hotel, Factory, etc.) Total Contract Value Firms Contract Value Approx. Completion Date 12 Please give an approximate percentage breakdown of the following professional services during the last financial year: Architectural Civil Engineering Structural Engineering Mechanical Engineering Electrical Engineering Heating and Ventilation Engineering Others (please list) TOTAL Please give an approximate percentage breakdown of the following work applicable to answers in question 8. Residential Buildings Offices and shops High Rise Contracts (10 storey +) Universities/Schools/Hotels Warehouses/Factory Buildings Soil/Piling Foundation Work Air Conditioning/Heating/Ventilation Highways and Roads Water/Sewage/Electrical Supply Land Fill/Land Fill Reclamation Cold Storage/Refrigeration Other (please list) TOTAL 100 5

6 14 Please give details of staff involved in design or professional activities: Qualifications Date Qualified Position Title Length of Time as such and extent of experience Qualifications Date Qualified Position Title Length of Time as such and extent of experience Qualifications Date Qualified Position Title Length of Time as such and extent of experience Qualifications Date Qualified Position Title Length of Time as such and extent of experience Qualifications Date Qualified Position Title Length of Time as such and extent of experience 6

7 15 Please give details of: a) Any claims arising from alleged professional negligence, error or omission b) Any circumstances of which, AFTER ENQUIRY, any director, partner or employee is aware that may give rise to a claim. 16 Please tick to indicate Limit of Indemnity required 250, , Please give details of existing insurance: a) of Insurer b) Indemnity Limit c) Date of Expiry Has any insurance: a) been declined or has renewal been refused? b) been terminated? c) had special terms imposed? If Yes please give details 18 Are you willing to accept responsibility for a higher amount (i.e. a higher excess) than the first 1000 of each and every Professional Indemnity claim under this policy? If so, please indicate how much: 2,500 5, If you require Retroactive Cover please specify the Retroactive Date required We will specify in the schedule issued a retroactive date. Cover will not apply to claims made against the Insured by reason of negligence committed or alleged to have been committed prior to this retroactive date. Unless you wish us to consider an alternative date the retroactive date will be the inception of Professional Indemnity cover under this policy. 7

8 PART B Additional Information 8

9 PART C Declaration If you have not given full and true answers to all questions asked on this Proposal, your insurance cover may not protect you in the event of a claim. If you wish to disclose something that has not been disclosed elsewhere on this Proposal, please use the box provided here. Before signing the Declaration, please read the notices on this page about the Claims and Underwriting Exchange Register and Data Protection Notice. Claims and Underwriting Exchange Register Insurers pass information to the Claims and Underwriting Exchange Register run by Insurance Database Services Limited (IDS Ltd). The aim is to help us check information provided and also to prevent fraudulent claims. When we deal with your request for insurance we may search the register. When you tell us about an incident (such as fire, water damage or theft) which may or may not give rise to a claim, we will pass information relating to it to the register. You can ask us for more information about this. You should show this notice to anyone who has an interest in property insured under this policy. Data Protection Notice AXA Insurance UK plc is a member of the AXA Group. To set up and administer your policy we will hold and use information including sensitive personal information (sensitive personal information may include such things as criminal convictions and health information) about you supplied by you. We may send it in confidence for processing to other companies in the AXA Group (or companies acting on our instructions) including those located outside the European Economic Area. By signing this form you consent to such use of your personal data including sensitive data. AXA Insurance UK plc may send you details of our other products and services. To enable them to send you details of their services, we may also share your name and address with: other AXA companies based within the European Economic Area other carefully selected companies outside the AXA Group. You may be contacted in writing or by telephone or fax. If you do not wish to receive such details, please tick the appropriate box(es). Declaration Please read the Declaration carefully and then sign below. If there is more than one Proposer both should sign. I/We understand that if true answers have not been given that this insurance may not protect me/us in the event of a claim. I/We declare that the answers given to questions asked in this Proposal are true and complete to the best of my/our knowledge and belief. I/We understand that any material fact, which is information that may influence the Company in the acceptance of this insurance and the terms provided, has been disclosed and recorded. I/We understand that you will pass the information on this form and about any incident I/we may give details of to IDS Ltd so that they can make it available to other insurers. I/We also understand that, in response to any searches you may make in connection with this application or any incident I/we have given details of, IDS Ltd may pass you information it has received from other insurers about other incidents involving anyone insured under the Policy. I/We agree to accept the terms and conditions contained in the AXA Insurance UK plc Policy applying to this Proposal. Signature of Proposer Date Position in company No cover is in force until the Proposal has been accepted by AXA Insurance. 9

10 AXA is a world leader in wealth management and financial protection. We operate in over 50 countries and serve more than 50 million customers worldwide. We cater to a wide range of needs, providing advice and guidance to our individual and corporate customers on a variety of financial products and services. In addition to Business, Motor and Home Insurance we also offer Investments, Life Assurance, Retirement Planning, Long Term Care, Asset Management, Medical Insurance, Medical Insurance and Dental Payment Plans. With our expertise and commitment to customer service and consistent, quality care, you can rely on AXA for lasting security. Ask about AXA s excellent range of business, Home and Motor Insurance Products WLI346R/X-A (10/13) (34911) AXA Insurance UK plc Registered Office: 5 Old Broad Street, London EC2N 1AD. A member of the AXA Group of Companies. AXA Insurance UK plc is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Telephone calls may be monitored or recorded.

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