THIS APPLICATION FORM IS DESIGNED FOR SMALL & MEDIUM SIZED FIRMS/CORPORATIONS. PLEASE DO NOT COMPLETE THIS FORM:

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1 IMPORTANT NOTICES IES-NTUC Income Professional Indemnity Insurance Scheme for Engineering Consultants (Part 1) THIS APPLICATION FORM IS DESIGNED FOR SMALL & MEDIUM SIZED FIRMS/CORPORATIONS. PLEASE DO NOT COMPLETE THIS FORM: 1. If you are a Sole-Proprietor/Partnership/Corporation, and a. the total gross fee income of the Insured Firm(s)/Corporation(s) exceeds S$5,000,000 of your last audited financials; or b. there are more than 15 Registered Professional Engineers or more than 50 Engineering Practitioners* in the Insured Firm(s)/Corporation(s); or c. you are a Multi-disciplinary Firm/Corporation 2. If you are an Individual, earning more than S$500,000 per annum in your last income declaration for your Professional Engineering Work Who should sign this form This Application Form must be signed by a Principal / Partner / Director (as applicable) All questions must be answered You must answer all questions. If any question does not appear to be applicable, please indicate NA. If space for any answer is insufficient, please attach separate sheets identifying the questions by number. Claims Made Policy The Policy applied for is written on a Claims Made form. This means that the Policy will only respond to a claim that is first made against you and notified to the insurers during the period of insurance. In this respect, notification is also required of any allegation, fact, incident or circumstance (collectively referred to as circumstances ), which may give rise to a claim, of which you know or ought to have known during the period of insurance. Unless provided otherwise, the Policy will respond to a claim from such notified circumstances, even if it is made subsequent to its expiry. For the avoidance of doubt, the cover provided is subject to the retroactive date specified in the policy, and all other terms and conditions of the insurance. The cover will apply to claims that arise from work done since that retroactive date. The Policy excludes all claims, and circumstances, which may give rise to a claim, of which you knew or ought to have known prior to the policy inception. Other Matters The completion and signing of this Application Form does not bind you or the insurers to complete the insurance. Please send the original signed application form to the following address: Lockton Companies (Singapore) Pte Ltd 1 Raffles Place, #12-62 One Raffles Place, Tower 2 Singapore You may contact the following persons for information and assistance: Mr Chin Ah Faat } Tel No ahfaat.chin@asia.lockton.com Ms Tracy Ho } Tel No tracy.ho@asia.lockton.com Mr C. Nandakumar } Tel No c.nandakumar@asia.lockton.com Fax No

2 IMPORTANT NOTICE: THIS APPLICATION FORM IS DESIGNED FOR SMALL & MEDIUM SIZED FIRMS/CORPORATIONS. PLEASE DO NOT COMPLETE THIS FORM: 1. If you are a Sole-Proprietor/Partnership/Corporation, and a. the total gross fee income of the Insured Firm(s)/Corporation(s) exceeds S$5,000,000 in your last audited financials; or b. there are more than 15 Registered Professional Engineers or more than 50 Engineering Practitioners* in the Insured Firm(s)/Corporation(s); or c. you are a Multi-disciplinary Firm/Corporation 2. If you are an Individual, you are earning more than S$500,000 per annum in your last income declaration for your Professional Engineering Work As required under Section 25(5) of the Insurance Act Chapter 142 or any subsequent amendment thereof, you are required to fully and faithfully disclose in this Application Form all facts and matters which you know or ought to know, otherwise the Policy issued pursuant to this Application Form may be void Name of Practice(s) Principal Address Address of any other offices (if applicable) Telephone / Fax / Is the Practice(s) GST Registered?: YES NO IES Member Name / Membership No. You are a (please tick the applicable boxes) Sole Proprietor Unlimited/Limited Liability Partnership Unlimited/Limited Liability Corporation Individual (Freelance Consultant) Claims and Insurance Details 1. Is the Sole-proprietor, or any of the partners or directors (where applicable) or employees ever been subject to disciplinary proceedings for professional misconduct? YES NO 2. Have any claims for negligence or breach of professional duty been made in the last three years against the Practice(s), or any of its predecessors in business, or any prior practice of any of their present or former principal, partners or directors, or have circumstances been notified to insurers that might give rise to a claim? YES NO 3. Is the Sole-proprietor, or any of the partners or directors (where applicable), AFTER ENQUIRY, aware of any claim or circumstances that might give rise to a claim against the Practice or its predecessors in business, or any prior practice of any of their present or former principal, partners or directors? YES NO If you have answered Yes to any of the above three questions, please provide details by separate attachment. All notifications/allegations/claims in respect of work done, to be made known to Lockton immediately or as soon as you become aware. Failure to do so may result in the repudiation of the policy. 2 Please proceed to the next pages(s)

3 Name of Practice(s) : Details of your staff 1. Particulars of ALL Registered Professional Engineers (as currently placed in the Register of the Professional Engineers Board for the purposes of the Professional Engineers Act Cap 253 or as amended) who are Principal/Partners/Directors/Employees of the abovementioned Practice(s) at the date of this Application Form Names as in their Practising Certificates PE Registration No. Year first registered Designation Please state Specialisation (C&S/ Mechanical/ Electrical) 2. Are any of the Registered PEs above either (i) an Accredited Checker (Building Control Act), (ii) an Authorised Examiner (Workplace Safety & Health Act), (iii) a Registered Inspector (Fire Safety Act), or (iv) an Electrical Engineer (Electricity Act), or (v) a Geotechnical Specialist (PE Act)? YES NO If the answer to the above is Yes, please state their name and their respective registrations here: 3. Please state the number of Engineering Practitioners in your Practice(s) other than the above PEs: * Engineering Practitioner is defined as either a PE or a partner/director/employee who holds the requisite educational qualifications for registration as a PE with the Professional Engineers Board of Singapore but is not currently registered as a PE. For the avoidance of doubt, engineering diploma holders, technicians, administrative staff need NOT be included here, as it will affect the premium quoted) (Please use additional sheet(s) of paper, if necessary) 3

4 Other Questions IES-NTUC Income Professional Indemnity Insurance Scheme for Engineering Consultants (Part 1) 1. Limit(s) of Indemnity required for each and every claim (eec) and in the aggregate (agg) S$250,000 eec/agg S$500,000 eec/agg S$1,000,000 eec/agg S$2,000,000 eec/agg S$3,000,000 eec/agg 2. Your Annual Total Revenue 3. Deductible: Annual Total Revenue Deductible Please tick Below S$500,000 S$500,001 to below S$1,000,000 S$1,000,001 to below S$3,000,000 S$3,000,001 to below S$5,000,000 S$5,000 eec S$10,000 eec S$20,000 eec S$30,000 eec 4. What is the retroactive date? (As per your expiring policy schedule) 5. Are you involved in Project Management? YES NO If Yes, what percentage of Annual Total Revenue is Project Management work? 6. For Civil & Structural Engineers: Are you involved in Geotechnical work? If so, what is the percentage of such work? 7. Would you require a letter from the Insurer to state that the policy complies with Section 24 of the Professional Engineers Act? YES NO 4

5 Declaration I/We declare that the particulars given above are true and correct at the time of this application. I/We confirm that I/We understand and consent, and if I/We am/are submitting information relating to another individual, I/We represent and warrant that I/We have the authority to provide that information to the Insurance Broker, Lockton Companies (Singapore) Pte Ltd (Lockton Singapore). I/We have informed the individual about the purposes for which his/her personal information is collected, used and disclosed as well as the parties to whom such personal information may be disclosed by Lockton Singapore, as set out in the contents of the consent and authorisation clause contained below and the individual agrees and consents that Lockton Singapore may collect, use and process my/his/her personal information (whether obtained in this application form or otherwise obtained) and disclose such information to the following, whether in or outside of Singapore: i) Lockton s group of companies including its partners and associates; ii) insurers/reinsurers and/or their representatives; iii) lawyers; iv) loss adjustors/surveyors/claims advisors/claims adjustors; and v) governmental/regulatory authorities, courts, other alternative dispute resolution forums for the purposes stated in Lockton Singapore s Data Privacy Policy which includes: a) Sourcing, negotiating and placing the requisite insurance policy(ies) including any reinsurance; b) Administering and managing my/our relationship with the insurer(s)/reinsurer(s); c) Handling of and managing claims notified under the insurance policy(ies) concerned including any reinsurance; d) Compliance with legal or regulatory obligations, risk management procedures; and e) Carrying our market research and analysis and satisfaction surveys. NOTE: Please refer to (and if submitting information relating to another individual, refer such individual to) the full version of Lockton Singapore s Data Privacy Policy available at: before you provide your consent, and/or the above representation and warranty. Signature: Full Name: Date: Name/ Stamp of Practice: Designation: Important Disclaimer: The role of the Institution of Engineers Singapore ( IES ) in the IES-NTUC Income Professional Indemnity Scheme is non-commercial, and acts only as a service to IES members by providing them with more options for their Professional Indemnity Insurance. Members should make their own assessment and decisions relating to their insurance requirements. The IES shall not be responsible for deficiencies (if any) in the policies. The role of Lockton Companies (Singapore) Pte Ltd is solely as Administrator in the management and claims handling of the Scheme. 5