Professional Indemnity Proposal For Miscellaneous Occupations

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Professional Indemnity Proposal For Miscellaneous Occupations"

Transcription

1 P F A.F.S Licence A.C.N Professional Indemnity Proposal For Miscellaneous Occupations IMPORTANT NOTICE This Proposal Form must be typed, or completed in ink and signed and dated by the Proposer: Please answer every question fully, and state NIL or NONE as applicable. Incomplete answers may not be accepted and can delay quotation. Should there be insufficient room in the Proposal Form for full details, please use the additional information section at the end of the Proposal. Please also attach any supporting information which you feel may assist us in understanding your professional business practice It is the duty of the Proposer to disclose all material facts to Underwriters. Where this is omitted, the Underwriters may avoid their obligation under the Policy. For the purpose of the Proposal and for all purposes relating to any policy issued pursuant to this Proposal, a material fact shall be deemed to be one that would be likely to influence an Underwriter s judgment and acceptance of your proposal. Upon acceptance of the Underwriters terms and conditions and payment of the premium, all information provided by the Proposer together with the guidance notes will be deemed to be incorporated in the contract between Underwriters and the Insured. Your Insurance includes a provision that has the affect of excluding or limiting OUR liability under the Insurance in respect of a loss by reason that you are, or have been, a party to an agreement that excludes or limits YOUR rights to recover damages from a party in respect of the loss. Copies of the Proposal Forms should be retained for your records. High Street Underwriting Agency - Professional Indemnity Proposal HSUA

2 YOUR DETAILS 1. Name Commencement date of Insured (Full names of all entities requiring cover including trading names): business 2. Contact Details Business Address: Suburb: State: Postcode: Phone: Fax: Mobile: Website: PERIOD AND LIMITS OF INSURANCE 1. Period of Insurance (a) Insurance cover is needed from: to: _ 2. Insurance Limits (a) For what limits of indemnity do you require quotation: $1,000,000 $2,000,000 $5,000,000 $ Other (please specify) (b) Do you require any of the following extensions? (i) Libel & Slander. (ii) Dishonesty of Employees. (iii) Loss of Documents. (iv) Unintentional Breach of Copyright. (v) Unintentional Breach of Confidentiality. BUSINESS PARTICULARS 1. Business Description Full description of your Business: High Street Underwriting Agency - Professional Indemnity Proposal HSUA

3 2. Fees Please give the total annual gross fees for advice given in each of the last two Financial Years and an estimate for the current 12 months: Year Australia Overseas Estimated Current Financial Year $ $ Last Financial Year $ $ Previous Year $ $ Please state the date of your Financial Year End : 3. Qualifications Please list all Partners/Directors/Principals of your Firm: Please give total number of: Partners/Directors/Principals: _ Qualified staff: Other Staff: 4. Sub-Contractors (a) Do you use sub-contractors? Date Obtained - If '', please provide further details below: (b) Estimated Annual Payments $ (c) Nature of work performed: (d) Do all sub-contractors carry their own professional indemnity insurance? (e) Names in Full Qualifications - If '', to what limit of Indemnity $ Do you always check the Insurance s of sub contractors? How long a Partner/ Director/Principal 5. Other Information (a) Does the firm enter into any written agreements or letter of appointment? If '', please enclose copies. (b) Does the firm issue any literature, etc. describing the services If '', please enclose examples High Street Underwriting Agency - Professional Indemnity Proposal HSUA

4 (c) Please provide details of the five largest Contracts undertaken in the past 5 years: Title of Contract Fee (d) Please provide details of the two largest Contracts expected to be undertaken in the forthcoming year: Title of Contract Fee (e) Are you involved in any process of manufacture, construction, alteration, repair, installation or sale or supply of materials and equipment, other than in a pure consultancy capacity as previously described? (f) If '', Please give full details: (g) (h) Has the Firm or any of the Partners/Directors/Principal ever been a member of consortium or a joint venture? If '', Please give full details: (i) (j) Do you require this insurance to provide for legal actions bought? (a) Only in the Courts of Australia. (b) In Courts anywhere in the world other than the USA & Canada. Does the Firm or any Partners/Directors/Principals have an association with or a financial interest in any other firm or organisation? If '', Please give full details: 6. Business Operations Outside Australia (a) Do you operate outside Australia? - If '', please provide further details below: (b) Location Operations Annual Gross Fees High Street Underwriting Agency - Professional Indemnity Proposal HSUA

5 7. USA and Canada (a) Have you given Power of Attorney to any person or corporation in the USA or Canada? (b) Do you have any assets/company located in the USA or Canada? (c) Do you have any employees or other representatives in the USA or Canada? (d) Please supply copies of all contracts in relation to the USA or Canada. 8. Claims / Insurance History (a) Do you currently have insurance? If '', Please complete the following: Please advise the name of the holding Underwriter: _ Limit of Indemnity: $ Excess applicable: $ Expiry Date: Has any claim for professional negligence, error or omission ever been (b) made against the Firm and or Partners/Directors/Principals or employees and or their predecessors in the Firm whether insured or not? - If '', please provide further details below: Date Particulars Cost Name of Insurer (if any) (c) Are any of the Partners/Directors/Principals or employees AFTER ENQUIRY aware of any circumstances which are likely to give rise to a claim against the Firm or its predecessors in business or any of its present or former Partners/Directors/Principals or employees? - If '', please provide further details below: Date Particulars Cost Name of Insurer (if any) (d) Has any insurer ever declined indemnity for any claim made by you? - If '', please provide further details below: (e) Has any insurer declined, refused to renew, cancelled or imposed special conditions to any policy of insurance held by you? - If '', please provide further details below: High Street Underwriting Agency - Professional Indemnity Proposal HSUA

6 DECLARATION I/We declare and warrant that after enquiry all statements and particulars contained in this proposal and addenda are true and that no information whatever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this proposal and should the above particulars alter in any way I/We will advise the Underwriters as soon as practicable. I/We understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of the proposal may result in the Underwriters refusing to provide indemnity or voiding the policy in every respect. I/We hereby agree and accept that this Declaration shall be the basis of the contract between both parties if entered into. For and on behalf of (Name of Company):_ Signature : Dated: (print and sign in pen) Name of Signatory: Position: Where the answers are not in my/our handwriting they have been checked jointly and/or severally by me/us and are certified as correct. Signature : Dated: (print and sign in pen) Signing of this Proposal Form does not bind the Proposer or Underwriters to complete a contract of Insurance. Form Return Details Please return the completed form to your Insurance Broker For Brokers Only, please return this form to P F E W High Street Underwriting Agency - Professional Indemnity Proposal HSUA

7 ANY ADDITIONAL INFORMATION YOU WISH TO PROVIDE High Street Underwriting Agency - Professional Indemnity Proposal HSUA

Public & Products Liability Proposal

Public & Products Liability Proposal P 1800 096 829 F 1800 096 680 A.F.S Licence 244370 A.C.N 096 939 169 Public & Products Liability Proposal IMPORTANT NOTICE This Proposal Form must be typed, or completed in ink and signed and dated by

More information

Contractors All Risks Proposal

Contractors All Risks Proposal P 1800 096 829 F 1800 096 680 A.F.S Licence 244370 A.C.N 096 939 169 Contractors All Risks Proposal IMPORTANT NOTICE This Proposal Form must be typed, or completed in ink and signed and dated by the Proposer:

More information

PROFESSIONAL INDEMNITY INSURANCE ESTATE AGENTS, AUCTIONEERS, SURVEYORS & VALUERS

PROFESSIONAL INDEMNITY INSURANCE ESTATE AGENTS, AUCTIONEERS, SURVEYORS & VALUERS PROFESSIONAL INDEMNITY INSURANCE ESTATE AGENTS, AUCTIONEERS, SURVEYORS & VALUERS This proposal must be completed in ink by a Partner, Director or Principle of the Firm. If there is insufficient space to

More information

MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM

MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM IMPORTANT Please read these guidance notes before completing the Proposal Form. Where further information is required please refer to your Broker / Insurance

More information

MISCELLANEOUS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE

MISCELLANEOUS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE HCC International Walsingham House, 35 Seething Lane London EC3N 4AH, United Kingdom main +44 (0)20 7702 4700 facsimile +44 (0)20 7626 4820 MISCELLANEOUS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE

More information

Marketform Miscellaneous Professional Indemnity Proposal Form

Marketform Miscellaneous Professional Indemnity Proposal Form Marketform Miscellaneous Professional Indemnity Proposal Form IMPORTANT Please read these guidance notes before completing the Proposal Form. Where further information is required please refer to your

More information

MARINE SURVEYORS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE

MARINE SURVEYORS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE HCC International Walsingham House, 35 Seething Lane London EC3N 4AH, United Kingdom main +44 (0)20 7702 4700 facsimile +44 (0)20 7626 4820 MARINE SURVEYORS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE

More information

MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM

MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM Please Note: This is a proposal form for a policy relating to claims made against the Insured during the period of the policy only CLAIMS MADE. Please

More information

(Accountants) Proposal Form

(Accountants) Proposal Form Office Use: Company Ref Pos Caunce O Hara & Co Ltd City Wharf New Bailey Street Manchester M3 5ER Tel: 0161 833 2100 Fax: 0161 839 2100 (Accountants) Proposal Form PLEASE ENCLOSE WITH THIS PROPOSAL FORM:

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM Please answer all questions fully and if you have a brochure or any other information concerning your business please attach to this proposal. 1. Name of

More information

MISCELLANEOUS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL

MISCELLANEOUS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL 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

More information

Professional Indemnity Insurance for Specialist Consultants/Firms Proposal Form

Professional Indemnity Insurance for Specialist Consultants/Firms Proposal Form Professional Indemnity Insurance for Specialist Consultants/Firms Proposal Form Professional Indemnity Insurance for Specialist Consultants/Firms Proposal Form Please read the following carefully before

More information

PROFESSIONAL INDEMNITY INSURANCE

PROFESSIONAL INDEMNITY INSURANCE PROFESSIONAL INDEMNITY INSURANCE MISCELLANEOUS PROPOSAL FORM GUIDANCE TES This proposal must be completed in ink by a Partner or Director of the Proposer. Please use your headed notepaper to provide full

More information

ARCHITECTS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE

ARCHITECTS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE HCC International Walsingham House, 35 Seething Lane London EC3N 4AH, United Kingdom main +44 (0)20 7702 4700 facsimile +44 (0)20 7626 4820 ARCHITECTS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE IMPORTANT

More information

Paul Donnelly Insurance Brokers

Paul Donnelly Insurance Brokers Paul Donnelly Insurance Brokers Professional Indemnity Insurance Application Form Pty Ltd www.pauldonnellybrokers.com.au Suite 1, Jubilee Towers, 107 Pacfic Hwy Hornsby NSW 2077 PO BOX 97, Berowa, NSW

More information

Breeze Underwriting Application Form Accountants Professional Indemnity Insurance

Breeze Underwriting Application Form Accountants Professional Indemnity Insurance Application Form Accountants Professional Indemnity Insurance Send quotation requests to: Email: distribution@breezeuw.com.au Phone: 1300 556 826 IMPORTANT NOTICES Please read these Important tices before

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL NOTICE TO INSURED (Pursuant to the provisions of the Insurance Contracts Act 1984) Your Duty of Disclosure Before you enter into a contract of general insurance with an insurer, you have a duty, under

More information

MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM

MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM Centry Gothic Please read the following questions carefully and answer them all providing additional information where required. Should you require more

More information

IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM

IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Management Consultants Professional Indemnity Insurance Proposal Form IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Method of Completion This proposal form may be completed in ink or electronically

More information

IMPORTANT NOTICE REGARDING COMPLETION OF THIS MANAGEMENT CONSULTANTS PROPOSAL FORM

IMPORTANT NOTICE REGARDING COMPLETION OF THIS MANAGEMENT CONSULTANTS PROPOSAL FORM IMPORTANT NOTICE REGARDING COMPLETION OF THIS MANAGEMENT CONSULTANTS PROPOSAL FORM 1. Disclosure - Any material fact must be disclosed to Insurers. - A material fact is any information which may alter

More information

IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM

IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Employment & Recruitment Agencies Professional Indemnity Insurance Proposal Form IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Method of Completion This proposal form may be completed in ink

More information

Professional Indemnity Insurance Proposal Form Miscellaneous

Professional Indemnity Insurance Proposal Form Miscellaneous Commercial & General Insurance Brokers (Aust) Pty Ltd Suite 4, 1016 Doncaster Road Doncaster East Victoria 3109 Phone: 1300 764 244 Fax: 03 8841 4299 Email: pi@cgib.com.au Web: www.cgib.com.au AFS License:

More information

MANAGEMENT CONSULTANTS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE

MANAGEMENT CONSULTANTS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE HCC International Walsingham House, 35 Seething Lane London EC3N 4AH, United Kingdom main +44 (0)20 7702 4700 facsimile +44 (0)20 7626 4820 MANAGEMENT CONSULTANTS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE

More information

Professional Indemnity Insurance for the Media Industry Advertising, Marketing, Public Relations and Sales Promotions

Professional Indemnity Insurance for the Media Industry Advertising, Marketing, Public Relations and Sales Promotions Professional Indemnity Insurance for the Media Industry Advertising, Marketing, Public Relations and Sales Promotions Proposal Form Professional Indemnity Insurance for the Media Industry Advertising,

More information

HOULDER INSURANCE SERVICES

HOULDER INSURANCE SERVICES HOULDER INSURANCE SERVICES PROFESSIONAL INDEMNITY PROPOSAL FORM ENGINEERS PLEASE READ THE FOLLOWING BEFORE COMPLETING THIS PROPOSAL FORM: ALL QUESTIONS SHOULD BE COMPLETED IN INK. WHERE A QUESTION IS NOT

More information

CONSULTING ENGINEERS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE

CONSULTING ENGINEERS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE HCC International Walsingham House, 35 Seething Lane London EC3N 4AH, United Kingdom main +44 (0)20 7702 4700 facsimile +44 (0)20 7626 4820 CONSULTING ENGINEERS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE

More information

Roderick Insurance Brokers

Roderick Insurance Brokers Roderick Insurance Brokers Professional Indemnity Insurance Application Form Please answer all questions. Blanks and/or dashes, or answers "known to underwriters or brokers" or "N/A" are not acceptable

More information

Miscellaneous Professional Indemnity Insurance

Miscellaneous Professional Indemnity Insurance Proposal Form Miscellaneous Professional Indemnity Insurance CorporateGuard This is a Proposal Form for a Policy relating only to claims first made against the Insured during the Policy Period. Please

More information

JUA Underwriting Agency Pty Ltd

JUA Underwriting Agency Pty Ltd JUA Underwriting Agency Pty Ltd Engineers & Architects Professional Indemnity Proposal Form Please answer every question fully, incomplete answers will not be accepted, and may result in a delay in terms

More information

MARKETFORM : SYNDICATE 2468 PROPOSAL FORM FOR DESIGN CONSULTANTS PROFESSIONAL INDEMNITY INSURANCE

MARKETFORM : SYNDICATE 2468 PROPOSAL FORM FOR DESIGN CONSULTANTS PROFESSIONAL INDEMNITY INSURANCE MARKETFORM : SYNDICATE 2468 BROKER / INSURANCE AGENT PROPOSAL FORM FOR DESIGN CONSULTANTS PROFESSIONAL INDEMNITY INSURANCE PLEASE READ THESE GUIDANCE NOTES BEFORE COMPLETING THE PROPOSAL FORM. WHERE FURTHER

More information

Professional Indemnity Insurance Proposal.

Professional Indemnity Insurance Proposal. ProJuris Professional Indemnity Professional Indemnity Insurance Proposal. Important information What is a proposal? This proposal tells us information, which we need to know in order to decide whether

More information

JUA Underwriting Agency Pty Ltd

JUA Underwriting Agency Pty Ltd JUA Underwriting Agency Pty Ltd Valuers Professional Indemnity Proposal Form Please answer every question fully, incomplete answers will not be accepted, and may result in a delay in terms being issued

More information

Professional Indemnity Proposal Form

Professional Indemnity Proposal Form Professional Indemnity Proposal Form IMPORTANT NOTES This insurance cover is based upon representations given to us by you. Should any particulars have changed or be incorrect you must notify us immediately.

More information

IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM

IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Media Professionals Professional Indemnity Insurance Proposal Form IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Method of Completion This proposal form may be completed in ink or electronically

More information

Miscellaneous Professional Indemnity Insurance Proposal form

Miscellaneous Professional Indemnity Insurance Proposal form Miscellaneous Professional Indemnity Insurance Proposal form Instructions Please provide a full answer to every question. Please ensure that all answers are typewritten or printed in block letters with

More information

1. NAME OF FIRM TO BE INSURED 2. ADDRESS OF FIRM 3. THE FIRM. (please include full names of all entities to be insured) Phone ( ) Email

1. NAME OF FIRM TO BE INSURED 2. ADDRESS OF FIRM 3. THE FIRM. (please include full names of all entities to be insured) Phone ( ) Email SURA Professional Risks Level 13 / 141 Walker St North Sydney NSW 2060 P O BOX 1813 North Sydney NSW 2059 Telephone. 02 9930 9500 Facsimile. 02 9930 9501 sura.com.au MISCELLANEOUS PROFESSIONAL INDEMNITY

More information

Engineers, Architects, Surveyors and Relation Professions

Engineers, Architects, Surveyors and Relation Professions Application Form Professional Indemnity Insurance Send quotation requests to: Email: distribution@breezeuw.com.au Phone: 1300 556 826 Engineers, Architects, Surveyors and Relation Professions IMPORTANT

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT TICES - `CLAIMS MADE CONTRACTS OF INSURANCE Please read the following carefully before completing this proposal form: Your professional indemnity

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT FACTS RELATING TO THIS PROPOSAL FORM The Purpose of this Proposal Form is to set out all relevant information for your adviser to submit on your

More information

Miscellaneous Professional Indemnity Insurance proposal form

Miscellaneous Professional Indemnity Insurance proposal form Miscellaneous Professional Indemnity Insurance proposal form Please complete all the questions in this proposal form in black ink, continuing your answers on page 7 where there is insufficient space. 1

More information

Professional Indemnity Proposal

Professional Indemnity Proposal Professional Indemnity Proposal IMPORTANT NOTICES Your Duty Of Disclosure This Policy is subject to the Insurance Contracts Act 1984. Under that Act you have a duty of disclosure. Before you take out insurance

More information

Professional Indemnity Insurance for Miscellaneous Professions Proposal Form

Professional Indemnity Insurance for Miscellaneous Professions Proposal Form Professional Indemnity Insurance for Miscellaneous Professions Proposal Form Important Notice 1. This is a proposal for a contract of insurance, in which Proposer or you / your means the individual, company,

More information

BUSINESS, EXECUTIVE, LIFE COACHES PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

BUSINESS, EXECUTIVE, LIFE COACHES PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM BUSINESS, EXECUTIVE, LIFE COACHES PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT FACTS RELATING TO THIS PROPOSAL FORM The Purpose of this Proposal Form is to set out all relevant information

More information

IT PROFESSIONALS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

IT PROFESSIONALS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IT Professionals Professional Indemnity Insurance Proposal Form IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Method of Completion This proposal form may be completed in ink or electronically

More information

HOULDER INSURANCE SERVICES

HOULDER INSURANCE SERVICES HOULDER INSURANCE SERVICES PROFESSIONAL INDEMNITY PROPOSAL FORM ARCHITECTS PLEASE READ THE FOLLOWING BEFORE COMPLETING THIS PROPOSAL FORM: ALL QUESTIONS SHOULD BE COMPLETED IN INK. WHERE A QUESTION IS

More information

4. DETAILS OF THE PRINCIPAL(S) OF THE FIRM How Long Practicing as Partner/Director

4. DETAILS OF THE PRINCIPAL(S) OF THE FIRM How Long Practicing as Partner/Director SURA Professional Risks Level 13 / 141 Walker St North Sydney NSW 2060 P O BOX 1813 North Sydney NSW 2059 Telephone. 02 9930 9500 Facsimile. 02 9930 9501 sura.com.au ACCOUNTANTS PROFESSIONAL INDEMNITY

More information

PROPOSAL FORM FOR IT CONSULTANTS PROFESSIONAL INDEMNITY INSURANCE

PROPOSAL FORM FOR IT CONSULTANTS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR IT CONSULTANTS PROFESSIONAL INDEMNITY INSURANCE Precision Underwriting (UK) Limited, 3 rd Floor, 14 Cullum Street, London, EC3M 7JJ. T: +44 (0) 20 7398 0800 F: +44 (0) 20 7398 0801 E:

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ADVERTISING AGENTS

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ADVERTISING AGENTS INTERSURE INSURANCE BROKERS LIMITED PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ADVERTISING AGENTS PLEASE READ THIS GUIDANCE NOTE BEFORE COMPLETING THE PROPOSAL FORM To help us to provide you with

More information

Design & Construct Professional Indemnity Insurance Proposal Form

Design & Construct Professional Indemnity Insurance Proposal Form Your Professional Indemnity Specialists www.brian-thornhill.co.uk Design & Construct Professional Indemnity Insurance Proposal Form Please complete this form in BLOCK CAPITALS IMPORTANT INFORMATION This

More information

UIB UK PROFESSIONAL INDEMNITY

UIB UK PROFESSIONAL INDEMNITY l It is very important that you disclose fully and accurately all material facts. If you require more space please continue on your headed paper, then sign and attach to this form. Material facts are those

More information

MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM

MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM MISCELLANEOUS PROFESSIONAL INDEMNITY PROPOSAL FORM IMPORTANT NOTICE TO THE PROPOSER TO COMPLETION OF THIS PROPOSAL FORM 1) Disclosure - Any material fact must be disclosed to Insurers. - A material fact

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM Answer all questions. Blanks &/or dashes, or answers known to underwriters or brokers or N/A are not acceptable & will delay consideration of this proposal.

More information

IMPORTANT NOTICE REGARDING COMPLETION OF THIS ACCOUNTANTS PROPOSAL FORM

IMPORTANT NOTICE REGARDING COMPLETION OF THIS ACCOUNTANTS PROPOSAL FORM IMPORTANT NOTICE REGARDING COMPLETION OF THIS ACCOUNTANTS PROPOSAL FORM 1. Disclosure - Any material fact must be disclosed to Insurers. - A material fact is any information which may alter the judgment

More information

Information Technology Consultants Proposal Form

Information Technology Consultants Proposal Form Proposal Form This Proposal form must be completed in ink, signed and dated by a Principal, Partner or Director of the Proposer. All questions must be answered and where appropriate not applicable or n/a

More information

Professional Indemnity Insurance for Specialist Consultants Proposal Form

Professional Indemnity Insurance for Specialist Consultants Proposal Form Professional Indemnity Insurance for Specialist Consultants Proposal Form Professional Indemnity Insurance for Specialist Consultants Proposal Form Please read the following carefully before completing

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ADVERTISING AGENTS PLEASE READ THIS GUIDANCE NOTE BEFORE COMPLETING THE PROPOSAL FORM To help us to provide you with our most competitive quotation, it

More information

ACCOUNTANTS, BOOKKEEPERS & RELATED PROFESSIONS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

ACCOUNTANTS, BOOKKEEPERS & RELATED PROFESSIONS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM ACCOUNTANTS, BOOKKEEPERS & RELATED PROFESSIONS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT FACTS RELATING TO THIS PROPOSAL FORM The Purpose of this Proposal Form is to set out all relevant

More information

Professional Indemnity Insurance (Miscellaneous Classes)

Professional Indemnity Insurance (Miscellaneous Classes) Proposal Form Professional Indemnity Insurance (Miscellaneous Classes) ADNIC is a Public Joint Stock Company incorporated in the United Arab Emirates by Law. (4) of 1972, and it is governed by the provisions

More information

SECTION 1 ABOUT THE PROPOSER (Please write in block capitals or cross the appropriate boxes as required)

SECTION 1 ABOUT THE PROPOSER (Please write in block capitals or cross the appropriate boxes as required) Proposal Form Professional Indemnity Insurance MISCELLANEOUS PROFESSIONS IMPORTANT NOTICE TO THE PROPOSER Please fully complete this Proposal Form. It is very important that the person completing the Proposal

More information

Land Surveyors Professional Indemnity Insurance Proposal Form

Land Surveyors Professional Indemnity Insurance Proposal Form Land Surveyors Professional Indemnity Insurance Proposal Form Important Information Answering the questions You must answer ALL questions in this proposal form. Failure to answer all questions in this

More information

IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM

IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Consulting Engineers Professional Indemnity Insurance Proposal Form IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Method of Completion This proposal form may be completed in ink or electronically

More information

Management Consultants Professional Liability Proposal Form

Management Consultants Professional Liability Proposal Form Notice:Statement pursuant to Section 25(5) of the Insurance Act (Cap 142) or any amendments thereof; You are to disclose in this application, fully and faithfully, all the facts which you know or ought

More information

Professional Indemnity Insurance Management Consultants Proposal Form

Professional Indemnity Insurance Management Consultants Proposal Form Professional Indemnity Insurance Management Consultants Proposal Form Towergate Lifestyle Suite 4b, 1 Portland Street, Manchester, M1 3BE Tel: 0844 892 1789 Fax: 0844 892 1796 Email: lifestyle@towergate.co.uk

More information

CONSULTING ENGINEERS PROFESSIONAL INDEMNITY PROPOSAL FORM

CONSULTING ENGINEERS PROFESSIONAL INDEMNITY PROPOSAL FORM CONSULTING ENGINEERS PROFESSIONAL INDEMNITY PROPOSAL FORM Please read the following questions carefully and answer them all providing additional information where required. Should you require more space

More information

PROFESSIONAL INDEMNITY INSURANCE

PROFESSIONAL INDEMNITY INSURANCE BDB (UK) Limited 40 Lime Street, London EC3M 7AW PROFESSIONAL INDEMNITY INSURANCE ACCOUNTANTS PROPOSAL FORM 1 GUIDANCE NOTES This proposal must be completed in ink by a Partner or Director of the Proposer.

More information

E nvironm ental Consultants

E nvironm ental Consultants Professional Indemnity Insurance Proposal for E nvironm ental Consultants PROFESSIONAL RISKS 2nd Floor John Stow House 18 Bevis Marks London EC3A 7JB Tel 020 7623 4957 Fax 020 7623 4958-1- PROFESSIONAL

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ARCHITECTS PLEASE READ THIS GUIDANCE NOTE BEFORE COMPLETING THE PROPOSAL FORM To help us to provide you with our most competitive quotation, it is important

More information

QBE PROFESSIONAL LIABILITY. Directors & Officers Liability INSURANCE PROPOSAL PROPOSAL

QBE PROFESSIONAL LIABILITY. Directors & Officers Liability INSURANCE PROPOSAL PROPOSAL QBE PROFESSIONAL LIABILITY Directors & Officers Liability INSURANCE PROPOSAL PROPOSAL Directors & Officers Liability tice to the Proposed Insured This notice must be read before you complete the proposal

More information

Professional Indemnity Insurance for Professional Risks of building and engineering contractors Proposal Form

Professional Indemnity Insurance for Professional Risks of building and engineering contractors Proposal Form Professional Indemnity Insurance for Professional Risks of building and engineering contractors Proposal Form Professional Indemnity Insurance for Construction Industry Professionals Proposal Form Please

More information

ARCHITECTS PROFESSIONAL INDEMNITY PROPOSAL FORM

ARCHITECTS PROFESSIONAL INDEMNITY PROPOSAL FORM ARCHITECTS PROFESSIONAL INDEMNITY PROPOSAL FORM Please read the following questions carefully and answer them all providing additional information where required. Should you require more space please provide

More information

PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE ACCOUNTANTS

PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE ACCOUNTANTS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE ACCOUNTANTS ACCOUNTANTS PROFESSIONAL INDEMNITY INSURANCE This proposal form must be completed in ink by a Partner, Principal or Director of the Firm or Company.

More information

Professional Indemnity Select

Professional Indemnity Select Allianz Insurance plc Professional Indemnity Select Insurance Brokers Proposal Form Insurance Professional Brokers Indemnity Professional Policy Overview Indemnity Select Insurance Brokers Professional

More information

Professional Indemnity Insurance for Chartered Surveyors Proposal Form

Professional Indemnity Insurance for Chartered Surveyors Proposal Form Professional Indemnity Insurance for Chartered Surveyors Proposal Form Professional Indemnity Insurance for Chartered Surveyors Proposal Form Please read the following carefully before completing this

More information

Professional Indemnity Proposal Form. for. Information Technology Consultants

Professional Indemnity Proposal Form. for. Information Technology Consultants Professional Indemnity Proposal Form for Information Technology Consultants Address: 5/3352 Pacific Highway Postal: PO Box 976 Springwood QLD 4127 Springwood QLD 4127 Phone: 07 3387 2800 Fax: 07 3208 2200

More information

THIS APPLICATION IS FOR A CLAIMS MADE POLICY

THIS APPLICATION IS FOR A CLAIMS MADE POLICY PEMBROKE SYNDICATE 4000 MISCELLANEOUS ERRORS & OMISSIONS INSURANCE APPLICATION THIS APPLICATION IS FOR A CLAIMS MADE POLICY ALL QUESTIONS MUST BE ANSWERED COMPLETELY. DO NOT LEAVE ANY SPACE BLANK. INDICATE

More information

Professional Indemnity Insurance for Insurance Intermediaries Proposal Form

Professional Indemnity Insurance for Insurance Intermediaries Proposal Form Professional Indemnity Insurance for Insurance Intermediaries Proposal Form Professional Indemnity Insurance for Insurance Intermediaries Proposal Form Please read the following carefully before completing

More information

Professional Indemnity Proposal Form. for. Accountants. Address: 5/3352 Pacific Highway Postal: PO Box 976. Springwood QLD 4127 Springwood QLD 4127

Professional Indemnity Proposal Form. for. Accountants. Address: 5/3352 Pacific Highway Postal: PO Box 976. Springwood QLD 4127 Springwood QLD 4127 Professional Indemnity Proposal Form for Accountants Address: 5/3352 Pacific Highway Postal: PO Box 976 Springwood QLD 4127 Springwood QLD 4127 Phone: 07 3387 2800 Fax: 07 3208 2200 Email: pidirect@pidirect.com.au

More information

THIS APPLICATION IS FOR A CLAIMS MADE POLICY

THIS APPLICATION IS FOR A CLAIMS MADE POLICY PEMBROKE SYNDICATE 4000 ACTUARIES ERRORS AND OMISSIONS INSURANCE APPLICATION THIS APPLICATION IS FOR A CLAIMS MADE POLICY ALL QUESTIONS MUST BE ANSWERED COMPLETELY. DO NOT LEAVE ANY SPACE BLANK. INDICATE

More information

Professional Indemnity Proposal Form Agricultural Consultants

Professional Indemnity Proposal Form Agricultural Consultants Rivers Insurance Brokers Pty Ltd (t) 07 3028 9494 PO Box 518, Annerley Qld 4103 (f) 07 3891 3111 23 Balaclava Street, Woolloongabba Qld 4102 ABN 28 010 242 681 AFS Lic. 247093 admin@riversinsurance.com.au

More information

Miscellaneous Professional Indemnity Insurance

Miscellaneous Professional Indemnity Insurance Miscellaneous Professional Indemnity Insurance Proposal Form 1. All questions must be answered giving full and complete answers. 2. Please ensure that this Proposal Form is Signed and Dated. 3. All fee

More information

MISCELLANEOUS PROFESSIONAL LIABILITY / GENERAL LIABILITY APPLICATION

MISCELLANEOUS PROFESSIONAL LIABILITY / GENERAL LIABILITY APPLICATION MISCELLANEOUS PROFESSIONAL LIABILITY / GENERAL LIABILITY APPLICATION COVERAGE PART A PROFESSIONAL LIABILITY INSURANCE COVERAGE THIS APPLICATION IS FOR A CLAIMS MADE INSURANCE POLICY Please read your policy

More information

Professional Indemnity

Professional Indemnity Professional Indemnity Proposal form New Business OR Renewal Policy number Intermediary Completion notes Please read the following before completing this document. Answer all questions in full. If you

More information

Professional Indemnity Insurance Facility for APCC Members

Professional Indemnity Insurance Facility for APCC Members Professional Indemnity Insurance Facility for APCC Members Professional Indemnity Insurance Facility for APCC Members PROTEAN RISK is as a specialist insurance broker focused on the needs of the investment

More information

Surveyors, Estate Agents and other Property Professionals Professional Indemnity Insurance

Surveyors, Estate Agents and other Property Professionals Professional Indemnity Insurance Surveyors, Estate Agents and other Property Professionals Professional Indemnity Insurance Proposal Form IMPORTANT INFORMATION REGARDING COMPLETION OF THIS FORM Method of Completion This proposal form

More information

Professional Indemnity Proposal Form. for. Financial Planners

Professional Indemnity Proposal Form. for. Financial Planners Professional Indemnity Proposal Form for Financial Planners Address: 5/3352 Pacific Highway Postal: PO Box 976 Springwood QLD 4127 Springwood QLD 4127 Phone: 07 3387 2800 Fax: 07 3208 2200 Email: pidirect@pidirect.com.au

More information

UIB UK PROFESSIONAL INDEMNITY

UIB UK PROFESSIONAL INDEMNITY l It is very important that you disclose fully and accurately all material facts. If you require more space please continue on your headed paper, then sign and attach to this form. Material facts are those

More information

Professional Indemnity Insurance

Professional Indemnity Insurance Professional Indemnity Insurance For Members of the Public Relations Institute of Ireland Public Relations Consultants Proposal Form Arranged in co-operation with: W Wood Limited London EC3A 8B United

More information

Liability Insurance Proposal

Liability Insurance Proposal Liability Insurance Proposal For Information Technology Entities Woodina Underwriting Agency Pty Ltd AFS Licence No. 418755 NOTICE TO INSURED (Pursuant to the provisions of the Insurance Contracts Act

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ARCHITECTS

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ARCHITECTS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ARCHITECTS This proposal form must be completed in black ink by a Partner, Principal or Director of the Company. All questions must be answered to enable

More information

Architects Professions

Architects Professions Architects Professions Application Form IMPORTANT: In this Application: You / Your refers to all firms to be insured under this arrangement, including any predecessor or previous business for which cover

More information

Security Consultants. Professional Indemnity. Proposal Form

Security Consultants. Professional Indemnity. Proposal Form Thompson Heath & Bond Limited 107 Leadenhall Street London EC3A 4AF Tel: +44 (0) 20 7469 0100 Fax: +44 (0) 20 7621 0661 www.thbgroup.com Lloyd s Broker Security Consultants Professional Indemnity Proposal

More information

AUCTIONEERS & VALUERS ASSOCIATION OF AUSTRALIA

AUCTIONEERS & VALUERS ASSOCIATION OF AUSTRALIA Professional Indemnity Insurance Proposal Form AUCTIONEERS & VALUERS ASSOCIATION OF AUSTRALIA IMPORTANT NOTICE Your Duty of Disclosure Before you enter into a contact of general insurance with any insurer,

More information

Medical Malpractice Insurance Proposal Form. for. Miscellaneous Medical Professionals

Medical Malpractice Insurance Proposal Form. for. Miscellaneous Medical Professionals Medical Malpractice Insurance Proposal Form for Miscellaneous Medical Professionals Address: 5/3352 Pacific Highway Postal: PO Box 976 Springwood Qld 4127 Springwood Qld 4127 Phone 07 3387 2800 Fax 07

More information

DESIGN AND CONSTRUCT PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE

DESIGN AND CONSTRUCT PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE Monometer House, Rectory Grove Leigh on Sea, Essex, SS9 2HN Office: 01702 713 636 Fax: 01702 713 691 DESIGN AND CONSTRUCT PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE IMPORTANT TICE This proposal must

More information

PUBLISHERS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE

PUBLISHERS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE HCC International Walsingham House, 35 Seething Lane London EC3N 4AH, United Kingdom main +44 (0)20 7702 4700 facsimile +44 (0)20 7626 4820 PUBLISHERS PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE IMPORTANT

More information

HOULDER INSURANCE SERVICES PROFESSIONAL INDEMNITY PROPOSAL FORM DESIGN & CONSTRUCTION INDUSTRY

HOULDER INSURANCE SERVICES PROFESSIONAL INDEMNITY PROPOSAL FORM DESIGN & CONSTRUCTION INDUSTRY HOULDER INSURANCE SERVICES PROFESSIONAL INDEMNITY PROPOSAL FORM DESIGN & CONSTRUCTION INDUSTRY PLEASE READ THE FOLLOWING BEFORE COMPLETING THIS PROPOSAL FORM: ALL QUESTIONS SHOULD BE COMPLETED IN INK.

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR ACCOUNTANTS PLEASE READ THIS GUIDANCE NOTE BEFORE COMPLETING THE PROPOSAL FORM To help us to provide you with our most competitive quotation, it is important

More information

ACCOUNTANTS PROFESSIONAL INDEMNITY PROPOSAL FORM

ACCOUNTANTS PROFESSIONAL INDEMNITY PROPOSAL FORM ACCOUNTANTS PROFESSIONAL INDEMNITY PROPOSAL FORM Centry Gothic Please read the following questions carefully and answer them all providing additional information where required. Should you require more

More information

Professional Indemnity Insurance. Proposal for PROFESSIONAL RISKS. 2nd Floor John Stow House 18 Bevis Marks London EC3A 7JB

Professional Indemnity Insurance. Proposal for PROFESSIONAL RISKS. 2nd Floor John Stow House 18 Bevis Marks London EC3A 7JB Professional Indemnity Insurance Proposal for IT Consultants PROFESSIONAL RISKS 2nd Floor John Stow House 18 Bevis Marks London EC3A 7JB Tel 020 7623 4957 Fax 020 7623 4958 PROFESSIONAL RISKS Kerry London

More information

Surveyors & Real Estate Professional Liability Proposal Form

Surveyors & Real Estate Professional Liability Proposal Form Notice:Statement pursuant to Section 25(5) of the Insurance Act (Cap 142) or any amendments thereof; You are to disclose in this application, fully and faithfully, all the facts which you know or ought

More information