Accountants Professional Indemnity Insurance

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1 Accountants Professional Indemnity Insurance Instructions Please provide a full answer to every question. A Partner/Director/Principal must sign and date this form and any separate sheets on behalf of the firm having consulted to ensure that the answers given are true and complete. Please include with this form a sheet of your current HEADED NOTEPAPER, which can also be used to supplement areas where you may have insufficient space to answer a question. Proposer Details Please note: If there are additional Insured s that cover is required for under this policy, you should answer all questions on this proposal form in relation to all parties to be insured under this policy. 1. Name of Firm(s) 2. Principal address, including post code: 3. Web-site address: Telephone : Fax : address: Fax : 4. Is the Firm(s) a subsidiary of an overseas parent company? 5. Please provide a description of your business activities: 6. Have the activities altered substantially since establishment and/or are any changes anticipated in the next 12 months? If, please provide full details 7. Are you connected or associated (financially or otherwise) to any other business? If, please provide full details Pegasus Professional Indemnity - Tel: Fax: Page 1 of 5

2 8. Are you a member of any Professional Association? If, please provide full details 9. a) Details of Principals/Partners/Directors: Name Age Qualifications Number of Years Experience b) Please confirm that one or more Principals have at least five years experience: If NO, please provide CV s for all Principals 10. Number of employees including principals/partners/directors: Qualified n Qualified 11. a) Give details of your fees/income derived from clients based in: Actual for Last Financial Year Estimate for Current Financial Year Estimate for Next Financial Year UK USA/Canada Elsewhere b) If any work is undertaken outside of the UK please give details of location, type of work and income derived: c) On what date does your financial year end? 12. What was the largest fee received from a single client during the last completed finiancial year? Pegasus Professional Indemnity - Tel: Fax: Page 2 of 5

3 13. What is the average fee received for the last complete financial year? 14. Have you ever undertaken work in the following areas: a) For Banks or other Financial Institutions/Pension Companies? b) For Insurance Companies, Lloyd s Syndicates/Names, Lloyd s Managing or Member Agents? c) For any Off Shore Companies? d) For Off Shore Funds/Investments (including Isle of Man & Channel Islands)? e) For clients in the Entertainment Industry? f ) For Solicitors? 15. Please indicate the approximate percentage of gross fees/income for each of the following during the past financial year: Auditing Preparation of accounts Compliance taxation Taxation consultancy Management consultancy Executorship & Trusteeship Insolvencies, liquidations and receiverships Investment advice Directorships Secretarial & share registration General insurance & building society commissions Work for merchant banks, finance houses, hire purchase and credit sales organisations and any other than building societies Computer Consultancy All other work (please give full details below) 100 Other: Pegasus Professional Indemnity - Tel: Fax: Page 3 of 5

4 16. Is the firm authorised, or has it been authorised in the past, to carry out investment or financial services work by the FSA? If, Please provide details of the extent of activities undertaken, and category of authorisation under the Financial services Act: 17. Do you use sub contractors? If, a) What percentage of fees are paid out to them: b) Please provide details of the work they carry out: c) Do you ensure that they have their own Professional Indemnity Insurance in force? 18. Do you currently have a professional indemnity insurance policy in force? If, please advise the Insurer Premium Renewal Date Retroactive Date 19. Please indicate the level(s) of indemnity you would like us to obtain quotations for: 250, ,000 1,000,000 Other: 20. A self-insured excess will apply to any claim. The Underwriter will decide what the minimum amount will be when assessing your risk however, if you prefer to carry a higher level of excess, which may reduce the premium, please indicate this below: 21. Do you currently have an individual(s) responsible for risk management strategy within your business? If, please provide full details: 21. Have you ever had any insurance or proposal cancelled, withdrawn, declined or made subject to special terms? If, please provide full details: Pegasus Professional Indemnity - Tel: Fax: Page 4 of 5

5 23. Have you sustained any loss through the fraud or dishonesty of any person or are you aware of any fraud or dishonesty at any time of any past or present partner, director or employee? If, please provide full details: 24. Has any claim, or are you aware of any circumstance that may give rise to a claim, whether successful or not been made against you or your predecessors in business or any past or present principal, partner, director or employee (whether insured or not)? If, please provide full details: SIGNING THIS PROPOSAL DOES NOT BIND THE PROPOSER TO COMPLETE THIS INSURANCE Declaration I/We declare that the statements and particulars in this proposal are true and that no material facts have mis-stated or suppressed after enquiry. I agree that this proposal, together with any other information supplied shall form the basis of any contract of insurance effected thereon. I undertake to inform the Insurers of any material alteration to those facts occurring before the completion of the contract of insurance. Signed Title (to be signed by Partner, Director or Principal or equivalent) Firm(s) Date Contact Details for Pegasus Professional Indemnity Please return the completed proposal form to: Pegasus Professional Indemnity 29 Cheapside, Bradford, West Yorkshire BD1 4HR Telephone: Fax: Web: Pegasus Professional Indemnity is authorised and regulated by the Financial Conduct Authority. Our firm reference number is. Pegasus Professional Indemnity - Tel: Fax: Page 5 of 5

100,000 250,000 500,000 1,000,000 2,000,000 Other Please Specify:

100,000 250,000 500,000 1,000,000 2,000,000 Other Please Specify: Intersure Insurance Brokers Limited Prospect House, 63 rth Street, Sudbury, Suffolk CO10 1RE Telephone: 01787 313133 Fax: 01787 313656 e-mail:enquiries@intersure.net www.intersureinsurance.com PROPOSAL

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