HOULDER INSURANCE SERVICES PROFESSIONAL INDEMNITY PROPOSAL FORM DESIGN & CONSTRUCTION INDUSTRY

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1 HOULDER INSURANCE SERVICES PROFESSIONAL INDEMNITY PROPOSAL FORM DESIGN & CONSTRUCTION INDUSTRY

2 PLEASE READ THE FOLLOWING BEFORE COMPLETING THIS PROPOSAL FORM: ALL QUESTIONS SHOULD BE COMPLETED IN INK. WHERE A QUESTION IS NOT APPLICABLE TO YOUR PARTICULAR CIRCUMSTANCES, PLEASE WRITE N/A. PLEASE TICK THE YES OR NO BOXES. IF THERE IS INSUFFICIENT SPACE TO ANSWER QUESTIONS PLEASE USE AN ADDITIONAL SHEET AND ATTACH IT TO THIS PROPOSAL FORM. COMPLETING AND SIGNING THIS PROPOSAL FORM DOES NOT BIND THE PROPOSER OR INSURERS TO COMPLETE THIS INSURANCE. IF THIS PROPOSAL RELATES TO A NEW BUSINESS OR VENTURE, PLEASE COMPLETE THE QUESTIONS AS FAR AS POSSIBLE, GIVING ESTIMATED OR ANTICIPATED INFORMATION. PPLCON-1 2

3 SECTION (1): DETAILS OF PROPOSER 1 Name of Individual or Firm requiring cover: 2 a) Principal address: Post Code: b) If other locations please specify town/city only: 3 Date established 4 Please provide details of all Partners, Principals or Directors: Please attach a CV for any unqualified Partner, Principal or Director PPLCON-1 3

4 SECTION (2): DETAILS ABOUT YOUR BUSINESS: 1 Please advise the total number of: a) Partners, Principals or Directors b) Qualified staff c) All other staff 2 If you are a sole Practitioner please advise: a) Details of your full time occupation (if any) b) What arrangements are in place in the event of sickness or holidays to ensure continuance of the business? 3 a) Do you engage consultants or sub-contractors? YES NO If YES please give details of the nature of activities undertaken by such consultants or sub-contractors: b) Do you check that the consultant or sub-contractors YES NO i) has appropriate qualifications? ii) maintains Professional Indemnity insurance? YES NO 4 Please give details of membership of any Association or Professional Body PPLCON-1 4

5 5 Do you use standard Contract Conditions/Letter of Appointment YES NO If YES please attach a copy If NO please provide details of how you define your duties to your client 6 Is work undertaken for any entity in which any Partner, Principal or Director YES NO of the Proposer is able to exercise a controlling interest? If YES please give full details and income derived from this source: 7 Are you associated financially or otherwise with any other entity? YES NO If YES please give full details: 8 Are you a member of a Consortium or Joint Venture? YES NO If cover is required in respect of your own liability as a member of the Consortium please provide the following:- a) Name of Consortium b) Type of services being provided c) Annual income/fees received from the Consortium PPLCON-1 5

6 9 Please confirm the total turnover for the last 2 completed financial years and the estimates for the current and forthcoming years: Territorial Split Year End Turnover U.K. Overseas (excl. USA/Canada USA/Canada)....% %..%.... % %..%....% %..%....% %..% 10 Please confirm the division of the total turnover specified above for the last completed financial year and an estimate for the current year. Turnover Where You:- Last Year Current Year i) Design and Construct from your own design and provide % % full supervision ii) Provide Design and Technical services with no construction % % iii) Construct from designs completed by others on your behalf % % iv) Construct from designs completed by others and technical supervision is carried out by other parties on your behalf % % v) Other turnover not specified above (please give details below): % % PPLCON-1 6

7 11 Please provide details of the 3 largest contracts during the last 5 years where you have undertaken or been responsible for the design services. Client Type of Services Total Date Date Project Performed Contract Value Commenced Finished i) ii) iii) 12 Please confirm the approximate division of each discipline where you have undertaken or been responsible for Design Services. Architecture % Chemical Engineering % Civil Engineering % Soil Engineering % Structural Engineering % Nuclear Engineering % Mechanical Engineering % Surveying - Land % Electrical Engineering % Surveying - Quantity % Heating & Ventilating Engineering % Surveying - Building % Other (please give details below) PPLCON-1 7

8 13 Please provide the approximate division of total work between the following activities: Home Building Industrial Building Individual Dwellings % Power Plants % Low Rise Multiple Dwellings % Refineries or Petro Chemical Installation % High Rise Multiple Dwellings % Manufacturing Plants % Modular Dwellings % Industrial Building Systems % Engineering Construction Amenities Highways % Hospitals & Nurses Homes % Bridges, Tunnels or Dams % Schools & Universities % Railways, Airports, Harbours or Jetties % Hotels or Recreation Centres % Sewerage/Water Schemes % Other (please give details below) % 14 Do you manufacture or fabricate any pre-engineered unit YES NO If YES please give details: 15 a) Have any major changes to your activities or structure taken place in the last 2 years? YES NO PPLCON-1 8

9 If YES please provide details: b) Are any major changes expected to your activities or structure in the next year? YES NO If YES please provide details: c) Have you carried out any activities other than those disclosed in this Proposal? YES NO If YES please provide details SECTION (3): YOUR P.I. REQUIREMENTS 1 Have you previously been insured or currently have Professional Indemnity Insurance YES NO in force? If YES please advise: a) Name of Insurers b) Renewal date c) Limit of Indemnity d) Excess e) The number of consecutive years you have been insured 2 What Limit of Indemnity do you require? 250, ,000 1,000,000 Other ( please specify amount): SECTION (4): PREVIOUS INSURANCE & CLAIMS HISTORY PPLCON-1 9

10 1 In respect of the Proposer or any Partner, Principal, Director has any Insurer ever YES NO cancelled, declined to provide or renew any Professional Indemnity Insurance or imposed special terms? If YES please give details: 2 Has any Partner, Principal, Director or Employee been subject to disciplinary proceedings by YES NO any Association or Professional Body? If YES please give details: 3 a) Has any claim, whether successful or not ever been made against the Proposer or its YES NO predecessors in business or any past or present Partner, Principal, Director or Employee? If YES please give details of dates, amounts claimed, allegations and current position PLEASE NOTE: If any Partner, Principal, Director or Employee is aware of any claim relating to activities carried out by them in previous practice or employment, details should be disclosed under this question. b) Are you or any Partner, Principal, Director or Employee AFTER FULL ENQUIRY YES NO aware of any circumstance or any circumstances which may give rise to a claim against the Proposer, its predecessors in business or any past or present Partner, Principal, Director or Employee? I/We declare that the statements and particulars given in this Proposal are correct and that no material fact has been omitted. I/We agree that this Proposal together with any other information supplied shall form the basis of the contract. Signature.. Position.. Date. PLEASE NOTE: It is necessary for you to disclose all Material Facts which may influence us in acceptance or assessment of this Proposal. Failure to do so could invalidate this insurance. If you are in doubt whether any fact is material you should disclose it. PPLCON-1 10

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