Professional Indemnity Insurance Proposal Form for Members of the INSTITUTE OF ENVIRONMENTAL MANAGEMENT AND ASSESSMENT ENVIRONMENTAL CONSULTANTS

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1 Professional Indemnity Insurance Proposal Form for Members of the INSTITUTE OF ENVIRONMENTAL MANAGEMENT AND ASSESSMENT ENVIRONMENTAL CONSULTANTS Please complete this form and return to: Tim FitzJohn S-Tech Insurance Services Ltd Victoria Road Cambridge CB4 3DZ Tel:

2 1. a) NAME OF COMPANY to be insured b) Address c) Date established d) Has the name of your Company changed or has any amalgamation or take-over taken place during the last ten years? If YES and cover is required for past work, please give details including the date of commencement and cessation of former Companies 2. a) Please fully describe your occupation b) Category of IEMA membership Affiliate Member Associate Member Full Member

3 3. Please provide details of your Company s Principal, Partners or Directors Full Name Age Qualifications Date Qualified. of years in this capacity in the company 4. How many permanent staff do you employ under the following headings? Qualified Technical All others 5. Do you employ Consultants under a contract for services with your Company? If so please provide details Full Name Age Qualifications Date Qualified. of years in this capacity in the company

4 6. If cover is required for any Partner or Director in respect of his/her liability arising from any previous business, please complete the following: Name Name of previous Company Date Partner left business 7. a) Please state the gross fees received by your Company. If a new Company indicate the anticipated fee income Estimate For Next Year Current Year Last Year Year UK USA/Canada Elsewhere TOTAL b) Percentage of fees paid to sub-contractors/consultants appointed by your Company % c) Largest fee from any one client d) Average fee from all clients e) Financial Year End date 8. Please provide details of the type of work undertaken last year under the following headings and the percentage of overall work Studies and General Advice % of total Assessments/Audits % of total

5 Investigations % of total Remedial Work % of total Waste % of total Any Other n Environmental Work % of total 9. a) Please provide details of the five largest contracts undertaken during the last five years Start Date Approximate Completion Date Firm s Contract Value Description of Services Performed b) Please give details of any major new operations being undertaken during the next twelve months

6 10. Please indicate which of the following sectors you have provided advice or consultancy to during the last completed financial year Developers % Oil and Gas Industry % Property Owners % Contractors % Chemical/Process Industry % Tenants % Lending % Power Indusrty % Others % Institutions (please specify) 11. Do you work under any legal jurisdiction other than that of the United Kingdom? If YES, please state where and the amount of work involved 12. Is your firm represented in any way in the USA or it s territories and possessions, or in Canada? If YES, please explain how (e.g. by subsidiary company, local office, local representative or by any other person or concern with the power of attorney to act on behalf of your firm)

7 13. Use of Sub Consultants a) Where you appoint sub consultants yourselves, do you ensure that they have Professional Indemnity Insurance for a limit not less than the amount of cover requested by this proposal? b) Please give details of sub consultants appointed, their qualifications and professional services c) Are any persons ever hired from outside agencies on a short term basis to carry out professional activites? If YES, please give full details, including controls exercised over them 14. a) Does your firm use a standard form of contract, agreement or letter of appointment? If YES, please enclose copies b) Please also enclose a copy of any brochures, leaflets etc describing your activites or service or advise your website address: www.

8 15. Does your Firm or any Partner or Director have any association with, or financial interest in, any other firm, company or organisation (other than as shareholders in a publicly quoted company)? If YES, please give details 16. Is your Firm or any Partner/Director a member of a consortium or joint venture? If YES, please provide the names of the other Members/Partners and their respective capacities in the consortium or joint venture, together with copies of any contracts or agreements 17. Does your Firm have a formal Quality Assurance System in place? If YES, please give full details:

9 18. Does your Firm currently hold Professional Indemnity Insurance? If YES, please state: i) Name of Insurers ii) Indemnity Limit iii) Excess iv) Renewal Date v) Premium 19. Does your firm always obtain satisfactory written references from former employers for the three years immediately preceding the engagement of any employee responsible for money, accounts or goods? 20. Has your Firm suffered any loss in the past five years through fraud or dishonesty of any employee? If YES, please state the date, circumstances, amount and steps taken to prevent reoccurence 21. Has any insurer, in respect of the risks to which this proposal relates declined a proposal, refused renewal, terminated the insurance or imposed special terms? If YES, please give details

10 22. Pollution Questionnaire a) Do you now or have you at any time in the past undertaken any of the following activities? If YES, please state approximate percentage of total gross fee income from the category in the last complete financial year and also the number of years that you have undertaken such work: Start Date Enviromental monitoring, studies, assessments, reports or audits Surveys or valuations of landfill or other waste disposal sites Surveys or valuations of property known to be polluted prior to survey Design or Supervision of remedial or clean up operations involoving polluted or contaminated property Management of any property which is known to be polluted or contaminated Project Management or Co-ordination relating to works which may give rise to pollution or contamination Evaluation, monitoring, design, closure or enclosure of landfill sites Any other work relating to waste disposal, treatment or management Work relating to air emission control systems Work relating to industrial piping or process systems Work relating underground storage facilities Work relating to hazardous chemical substances Any other work which may create liability for pollution or contamination (Please give details) / Fees Number of Years

11 b) Do you use standard forms of contract in relation to all work which contain a clause excluding or restricting liability for contamination? If YES, please attach a copy. For how long have you used such clauses? c) Please provide details of your experience in the Field of Pollution or Contamination, with particular reference to the individuals involved. CV s with reference to this aspect may be helpful te: It is essential that the following questions are answered correctly as failure to do so could prejudice your rights in the event of a claim arising 23. Have any claims for professional negligence, error or omission (successful or otherwise) been made against your Company or it s present and/or past Partners/Directors during the past ten years? If YES, please give full details and continue on a separate sheet if necessary 24. Is any Partner/Director of your Company, after having made full enquiries, aware of any circumstances which might give rise to a claim against or result in a loss to your Company or any predecessors in business or any of the present or former Partners/Directors? If YES, please give details including the maximum potential cost. Use a separate sheet if necessary

12 DECLARATION I/We declare that, after full enquiry, the contents of this form are true and that I/We have not misstated, omitted or supressed any material fact or information. I/We agree that this form together with any other information supplied by me/us shall be the basis of any contract of insurance which may be effected. If there is any material alteration to the facts and information which I/We have provided; or any new material matter arises before the completion of the contract of insurance, I/We undertake to inform underwriters. Signature of Partner/Director: Date: The insurance is not in force until the underwriters have accepted the proposal form. The European Union Third n-life Directive on Pre-Contractual Disclosure Requirements requires you to be provided with the following information prior to a contract being concluded. tice to the Proposer/Assurer. The parties are free to choose the Law applicable to this Insurance Contract. Unless specifically agreed to the contrary, this insurance shall be subject to English Law.

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