MISCELLANEOUS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL

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1 MISCELLANEOUS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL Pursuant to Paragraph 4(1) of Schedule 9 of the Financial Services Act 2013, if you are applying for this Insurance for a purpose related to your trade, business or profession, you have a duty to disclose any matter that you know to be relevant to our decision in accepting the risks and determining the rates and terms to be applied and any matter a reasonable person in the circumstances could be expected to know to be relevant, otherwise it may result in avoidance of your contract of insurance, refusal or reduction of your claim(s), change of terms or termination of your contract of insurance. The above duty of disclosure shall continue until the time your contract of insurance is entered into, varied or renewed with us. You also have a duty to tell us immediately if at any time after your contract of insurance has been entered into, varied or renewed with us any of the information given in this Proposal Form is inaccurate or has changed. 1. Name of Firm including any subsidiary or services companies to be covered under this insurance. 2. Address Profession / Occupation 3. When was the firm established? 4. Name of All Directors / Partners Qualification Year Obtained How long a D/P in Firm If less than 5 years practical experience in this occupation, please give details of previous occupations. 5. If sole Principal, please answer the following: is this a part-time occupation? If yes, please give details of present full time occupation. 6. Total number of Directors/Partners and staff or employees. (c) Directors / Partners Qualified Staff Other staff including office juniors and typists LG, 6 th, 7 th, 21st 26th Floor, Bangunan Public Bank, 6 Jalan Sultan Sulaiman, Kuala Lumpur. P. O. Box 10708, Kuala Lumpur. Tel: (03) , Fax: (03) Website:

2 7. Is the Firm/Partner(s) a member of a Professional Body or Association? 8. Does the Firm/Company conduct business from offices other than above? if so: Please state locations and address. Please state number of employee at these locations and details of control officer domiciled thereat. 9. In the past 5 years has the Firm / You ever changed your name or amalgamated / merged with another Firm/ Business? 10. Are you or any Partner/Director connected or associated (financially or otherwise) with any other Practice or Business? 11. Does the Firm perform work outside Malaysia, or work for foreign clients? 12. Breakdown of Annual gross fees: Item Territory Previous Year : 20 Current Year : 20 Next Year : 20 a) Malaysia b) Australia c) Europe d) USA/ Canada e) Rest of the World 13. Please categorise the activities Category Approx. Percentage 2

3 14. Please provide details of the five (5) largest contracts undertaken over the past five (5) years. Client Name Service Performed Start & End Date Location FEE (MYR) 15. Is the Firm/Company currently insured against Professional Negligence? If the answer to is NO has the firm/company ever been insured? (c) If the answer to or is YES please supply following data: Amount of Cover Amount of Excess Name of Insurer of Broker When lapsed or expiry date 16. Has any application for insurance in respect of the business to be covered made on behalf of its predecessors ever been declined, cancelled or renewal refused? Have any special terms ever been imposed? 17. Have any claims either successful or otherwise been made against the Firm / Company or any of the present Partners or against its predecessors in business or any past Partner? Are any of the partners or is the Company after enquiry aware of any circumstances which may give rise to claims other than 17 above, against the Firm / Company or their predecessors in business or any of the present or former Partners whether or not you consider yourself liable? If Yes, please give full details. 3

4 18. Precise nature of business Details of advice given. (c) Details of any disclaimers given on advice enclosing sample copies. (d) Are verbal reports always confirmed in writing? 19. Does the Firm use a standard form of contract, agreement or letter of appointment? If yes, please enclose copies. 20. Is any work put out to sub-contractors? If yes, please give details, including : Does the Firm require sub-contractors to carry insurance and for what limits? What percentage of the Firm s fees is paid to sub-contractors? 21. Please give details to any major new operations being undertaken during next 12 months. 22. Please comment on any features of your work which you think may be of interest to insurers. 23. Does the organisation issue any brochures, leaflets, books, etc. describing the organisation s services or offering any service or facility? If yes, Please enclose copies. 24. Is the organisation governed by any Act of Parliament? If yes, please enclose copy of relevant Act. 25. Does the organisation have or issue Regulations Code of Ethics (c) Memorandum of Association (e) By-Laws (g) Constitutions If yes to any of the above, please enclose copies. (d) Articles of Association (f) Annual Report 4

5 26. Amount of Indemnity required. What deductible are you prepared to carry in respect of each and every claim? 27. Indicate the extensions required: Loss of Documents Libel and Slander (c) Dishonesty (d) Outgoing Principal Limit desired: RM 28. Please give details of Partners or Principals. Who have joined the firm and from what previous firm? Who have retired and for whom the extension (d) question 28 is required including date of retirement from the firm. 29. If extension (c) (fidelity) is required: Has the Firm any Fidelity Guarantee in force at present? If yes, please give full details. Has the Firm/Company sustained any loss through the Fraud and Dishonesty of any Employee? If so, give details and state precautions taken to prevent a recurrence. (c) (d) Is any member of the Staff allowed to handle cash or transferable documents or sign cheques on his/her signature alone? How often and by whom are the entities in the cash book checked with the vouchers and recorded with the book statements and returned cheques? (e) Does the Firm/ Company always require and obtain satisfactory references when engaging employees? 5

6 DECLARATION I/We understand that it is my/our duty to take reasonable care not to make a misrepresentation in answering the questions in this Proposal Form and I/we hereby declare that I/we have fully and accurately answered the questions above. I/We hereby declare that the above statements are true, that I/We have not suppressed or mis-stated any facts, and that should any of the information given by me/us alter between the date of this Proposal and the inception date of the insurance to which this Proposal relates, I/We will give immediate notice thereof. I/We agree that this Proposal is for insurance in the normal terms and conditions of this Professional Indemnity Policy and shall be incorporated into and form the basis of the insurance contract. Name of Firm : Signed By (Partner) : Dated this day of 20 Note : Throughout this Proposal Form the word Partner(s) shall include: Principal(s), Director(s) and Officer(s) Enquiries should be made of all Partners/Directors/Consultants and staff to ensure full disclosure. It is imperative for your own protection that full details are disclosed. 6

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