Professional Indemnity Insurance Architects and Consulting Engineers - Annual Cover

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1 Professional Indemnity Insurance Architects and Consulting Engineers - Annual Cover Proposal Form ADNIC is a Public Joint Stock Company incorporated in the United Arab Emirates by Law No. (4) of 1972, and it is governed by the provisions of the UAE Federal Law No. (6) of 2007 Establishment of the Insurance Authority & Organization of its Operations, with Registration No. (1). Completing this form In order to apply for this insurance, please complete all parts of this proposal form and the annexures, if any. You must provide full, accurate, and true answers to all questions listed below. Material facts which you know or ought to know should be fully and accurately disclosed. Failure to do so may result in rejecting your claim and/or terminating the insurance policy from inception. If you are in any doubt about what you should disclose, please do not hesitate to contact us. A material fact is one that would influence our decision whether to offer you insurance or the terms which we offer. If the space provided is inadequate, please provide details using an additional information sheet, signed and dated. Your insurance does not commence when you sign the proposal. Your cover will only commence once we have reviewed the proposal form and confirmed cover in writing. Please keep a copy of this proposal form for your record along with any correspondence/ information provided to us and policies/endorsements that are issued to you subsequently. 1/9

Completing this form In order to apply for this insurance, please complete all parts of this proposal form and the annexures, if any.

2 1. General information a. Name of the firm: b. Address of head office: (Please show the address required on the policy) Contact person s name: P.O. Box: Country: Phone number: Fax number: City: Mobile number: address: Website address: c. Address of branch office(s) and name(s) of resident partner(s): P.O. Box: Country: Phone number: Fax number: City: Mobile number: address: Website address: 2. Scale of business In which countries do you carry out projects? 3. Firm details a. When was the firm established? b. During the past five years, has the name of the firm been changed or has any other firm been purchased or any merger or consolidation taken place? Yes No If so, give full details: 2/9

Box: Country: Phone number: Fax number: City: Mobile number: Email address: Website address: 2. Scale of business In which countries do you carry out projects? 3. Firm details a.

3 3. Firm details (continued) c. Details of all practising principals or partners Name Qualifications, dates qualified/total duration of professional experience Position held in company and for how long d. Total number of principals, partners and staff Technical: Principals, partners or officers Other qualified engineers Qualified architects Surveyors Draughtsmen Other qualified staff (please specify) Trainee staff (please specify) Total non-technical/administration staff Numbers 4. Nature of business a. Do you give work to independent firms, sub-contractors and/or specialists? Yes No If so, please state kind of work and percentage of fees: (The professional liability of such independent firms is not covered under the proposed policy.) b. Are you financially connected with a client? Yes No Name of the client: c. Is a major part of the work carried out for only one client? Yes No 3/9

Total number of principals, partners and staff Technical: Principals, partners or officers Other qualified engineers Qualified architects Surveyors Draughtsmen Other qualified staff (please specify)

4 5. Nature and volume of your present and foreseeable future activities a. In which of the following professions is your firm engaged? i) Civil engineering ii) Structural engineering iii) Mechanical engineering iv) Electrical engineering v) Heating and ventilating engineering vi) Chemical engineering vii) Soil engineering viii) Others, not shown Please specify: b. Division of the firm s activities % of total fees i) Feasibility studies, reports, surveys, etc. % Please specify projects ii) Bridges and/or tunnels and roads % iii) Dams, rivers and ports/harbours, jetties % iv) Mines, underground or subaqueous works % v) Airports % vi) Sewerage schemes, water supply % vii) Foundations and underpinning railway and subway % viii) Water schemes, agricultural engineering % ix) Nuclear or atomic projects % x) Chemical, petrochemical plants % xi) Housing schemes, architecture % xii) High-rise buildings % xiii) Schools, hospitals, municipal buildings % xiv) Industrialized system buildings % xv) Mechanical plant and bulk handling equipment % (including soils, etc.) xvi) Other works including any specialist activities not shown above (specify which): 4/9

Others, not shown Please specify: b. Division of the firm s activities % of total fees i) Feasibility studies, reports, surveys, etc.

5 5. Nature and volume of your present and foreseeable future activities (continued) c. Responsibilities i) Design only % ii) Supervision of construction % iii) Design and supervision % iv) Project management (turn-key contract) % (see also 6c.) d. Construction values and fees Past financial year Current financial year Coming financial year (estimate) i) Construction values ii) Gross fees received e. List some of the largest and typical jobs performed by your firm during the last five years (brief description including values and fees): 6. Further activities a. Do you also concern yourself with the sale and administration or real estate? Yes No b. Do you construct and sell houses and flats for your own account? Yes No c. Do you act as a project manager or main contractor? Yes No d. Are you an agent for goods used for construction or do you obtain commission from the sale or distribution of such goods? Yes No What goods? 5/9

Construction values and fees Past financial year Current financial year Coming financial year (estimate) i) Construction values ii) Gross fees received e.

6 6. Further activities (continued) e. Are you connected with firms constructing houses and flats or with auxiliary firms to the building industry or with other firms as a i) Member of the board? Yes No ii) Partner? Yes No iii) Shareholder (more than 3%)? Yes No Name of firms and activities: f. Do your activities include giving expert opinions? Yes No Also for municipal and state authorities? Yes No 7. Previous insurance/previous claims a. Have you previously been insured? Yes No If so, please specify: Policy wording on Name of insurer Policy period Claims-made basis Occurrence basis Limit of indemnity /9

Yes No ii) Partner? Yes No iii) Shareholder (more than 3%)? Yes No Name of firms and activities: f. Do your activities include giving expert opinions?

7 7. Previous insurance/previous claims (continued) b. Has a previous application been declined? Yes No Has a previous insurance i) Required increased premium? Yes No ii) Required special restrictions? Yes No iii) Been terminated/not been renewed by an insurer? Yes No If so, please give detailed information: c. Have any claims been made during the past five years against your firm? Yes No If so, please give details of paid claims including quantum and background of each claims: d. Is your firm aware of any circumstances or incidents which may result in a claim or claims against your firm? Yes No If so, please give details: 8. Indemnity required a. Limit any one accident: b. Limit in the annual aggregate: c. Deductible each and every claim to be borne by the insured: 7/9

Have any claims been made during the past five years against your firm? Yes No If so, please give details of paid claims including quantum and background of each claims: d.

8 9. Extension to basic cover a. Loss of documents Yes No Limit: b. Dishonesty of employees Yes No If so, please answer the following questions: i) Has the firm sustained any loss through the fraud or dishonesty of any employee? Yes No ii) Is any employee allowed to sign cheques without counter signature by a partner? Yes No If so, up to what amount? c. Libel and slander Yes No d. Partners previous business i) Incoming partners Yes No ii) Outgoing partners Yes No If this extension is required, please advise name of the partners and incoming/outgoing dates 8/9

dishonesty of any employee? Yes No ii) Is any employee allowed to sign cheques without counter signature by a partner?

9 Declaration I/We hereby declare that the statements/information given by me/us in the Proposal Form are full, accurate and true. It is hereby understood and agreed that the statements, answers and particulars provided in this Proposal Form and as per the attachments are the basis on which the insurance policy is being issued/effected. If after the insurance policy is effected, it is found that any fact in the statements, answers or particulars in this Proposal Form is incorrect, untrue, inaccurate, misrepresented or non-disclosed in any material respect, ADNIC shall have no liability under the insurance policy and/or shall have the right to terminate the insurance policy from inception. Name of Proposer: Title: Signature: Stamp: Date: Note: Please note that each page of the proposal form should be signed by the Proposer or its legal representative 9/9

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM ARCHITECTS AND CONSULTING ENGINEERS ANNUAL COVER

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM ARCHITECTS AND CONSULTING ENGINEERS ANNUAL COVER I. General data Name of firm. Address of head office. Address of branch office(s) and name(s) of resident