Professional Indemnity Insurance Proposal Form

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1 Professional Indemnity Insurance Proposal Form Certain Underwriters at Lloyd s and/or Companies (Insurers) acting through their agent International Underwriting Agencies Ltd ( IUA ) PO Box 7238, Wellesley Street, Auckland 1010 AUCKLAND P: F: Level 9, 52 Swanson Street, Auckland 1010, New Zealand PO Box 7238, Wellesley Street, Auckland 1141 CHRISTCHURCH P: F: Unit 11, 6-8 Cone Street, Rangiora 7400, New Zealand PO Box 774, Rangiora 7440 IMPORTANT This is a p r op osal f or m f or a claim s-m ad e Cert if icat e. The Cer t if icat e w ill only resp ond t o claim s and /or cir cum st ances w hich ar e f ir st m ad e against you and not if ied t o Int er nat ional Und er w rit ing Agencies Lim it ed d ur ing t he Cert if icat e p er iod. The Cer t if icat e w ill not p r ovid e cover f or : (a) Event s t hat occur red p r ior t o t he ret r oact ive d at e of t he Cert if icat e (if sp ecif ied ). (b ) Claim s m ad e af t er t he exp iry of t he Cert if icat e p er iod (or ext end ed r ep or t ing p er iod if availab le) even t hough t he Wr ongf ul Act giving r ise t o t he claim m ay have occur red d ur ing t he Cer t if icat e p er iod. (c) Claim s not if ied or ar ising out of f act s or cir cum st ances not if ied und er any p revious Cer t if icat e or not ed on t he cur r ent p r op osal f or m or any p r evious p r op osal f or m. (d ) Claim s m ad e, t hreat ened or int im at ed p r ior t o t he com m encem ent of t he Cer t if icat e p er iod. (e) Fact s or cir cum st ances in your know led ge p r ior t o t he Cer t if icat e p er iod w hich you knew had t he p ot ent ial t o give r ise t o a claim und er t he Cer t if icat e. This p r op osal f or m s t he b asis of any insur ance cont r act ent er ed int o. Please com p let e it f ully and car ef ully, r em em b er ing t o sign t he Declar at ion. If you d o not have enough r oom, p lease at t ach ad d it ional sheet s. Duty of Disclosure You have an ongoing d ut y t o d isclose all Mat er ial Fact s and f ailur e t o d o so could p r ejud ice f ut ure claim s. Mat er ial Fact s ar e t hose w hich m ay inf luence a p r ud ent insurer in d ecid ing w het her or not t o insur e you, on w hat t erm s, and at w hat p rem ium. Applicant details Name of applicant including trading names, names of subsidiaries and any parties required to be insured: Postal address: Website address: address: Contact person: Fax no:

2 Business details St at e t h e n at ure o f t h e p rof essio n /b usin ess in clud in g a f ull d escrip t io n o f yo ur act ivit ies an d in p ar t icular t h o se act ivit ies w h ere yo u p rovid e ad vice, d esign o r o p in io n w h ich m ay b e relied up o n b y a t h ird p ar t y: Cat ego rize yo ur act ivit ies an d co n f irm t h e p ercen t age o f yo ur t o t al in co m e (in clud i n g am o un t s p aid b y yo u t o sub co n t r act o r s o r co n sult an t s) f o r yo ur cur ren t year b y t h o se cat ego r ies: Activity Percentage (a) % (b ) % (c) % (d ) % (e) % (f ) % Total 100% In d icat e t h e n um b er o f years t h is b usin ess h as b een : Op erat in g: Ow n ed b y p resen t o w n ers: Man aged b y p resen t m an agem en t : List all accred it at io n s an d asso ciat io n m em b ersh ip s h eld b y yo ur b usin ess: Risk management details Have yo u im p lem en t ed f o rm al r isk m an agem en t p roced ures o r p lan s? Yes No If Yes, is ad h eren ce t o t h ese p roced ures p er io d ically review ed an d are kn o w n b reach es rect if ied? Yes No If No, w o uld yo u b e p rep ared t o w o rk w it h In t ern at io n al Un d er w r it in g Agen cies Gen eral In suran ce (N.Z.) Lim it ed in est ab lish in g such p roced ures? Yes No Are t h ere an y p ar t icular ch aract er ist ics o f yo ur b usin ess (e.g. risk m an agem en t pract ices, p rovisio n o f services t o sp ecialised m ar ket s et c) w h ich w o uld m at erially red uce o r in crease yo ur exp o sure t o p rof essio n al liab ilit y claim s in co m p ariso n t o p ract it io n ers in yo ur p ro f essio n gen erally? Yes No Do yo u em p lo y legal co un sel o r ret ain a p art icular f irm o f so licit o r s? Yes No

3 Administration and staff Please p rovid e t h e f o llo w in g d et ails in resp ect o f all curren t p rin cip als, p art n er s an d d irect o rs: Number of years as a Professional Name Year qualified Partner, Principal or qualifications Director Please p rovid e t h e f o llo w in g d et ails in resp ect o f all form er p r in cip als, p art n er s an d d irect o rs: Name Date left this business Reason for Leaving In d icat e t h e n um b er o f p erso n n el in each ap p licab le cat ego ry: Employees Contractors Full time Part time Full Time Part time Prin cip als, p art n er s an d d irect o rs Qualif ied p rof essio n als Ad m in ist rat ive an d clerical Ot h er (d escr ib e) Financial information What is t he d at e of your f inancial year -end? Please p rovid e gross f ees o r in co m e (in clu d in g f ees p aid t o sub co n t ract o r s) as f o llo w s: Current financial year Next financial year Country Last Financial year (estimate) (estimate) New Zealan d $ $ $ Aust ralia $ $ $ Asia an d t h e Pacif ic Islan d s Un it ed Kin gd o m & Europe $ $ $ $ $ $ USA/Can ad a $ $ $ Ot h er (sp ecif y) $ $ $ Total $ $ $

4 Wh at p ercen t age o f yo ur f ee in co m e is p aid t o sub co n t ract o rs o r co n sult an t s? % Please p rovid e d et ails o f t h e f ive largest co n t ract s un d er t aken d urin g t h e p ast f ive years: Name Description of Your major Duration contract responsibilities (a) $ (b ) $ (c) $ (d ) $ (e) $ Fees earned Contractual agreements Do yo u h ave st an d ar d t erm s up o n w h ich yo u sup p ly yo ur p rof essio n al ser vices? Yes No If Yes, p lease at t ach co p ies o f an y liab ilit y exclusio n clauses, d isclaim ers o r h o ld h arm less p rovisio n s. Will yo u o r h ave yo u en t ered in t o co n t ract s w it h h o ld h arm less p rovisio n s w h ich p rovid e t h at yo u w ill in d em n if y t h e o t h er p art y again st all claim s o r d em an d s? Yes No Wh en en gagin g in d ep en d en t co n sult an t s o r co n t ract o rs, d o yo u en sure t h at t h o se co n sult an t s: (a) Main t ain t h eir o w n p rof essio n al in d em n it y in sur an ce? Yes No (b ) Are b o un d b y co n t r act t o accep t f ull resp o n sib ilit y f o r t h eir o w n act io n s? Yes No Insurance history Have yo u ever h ad an y in suran ce d eclin ed o r can celled ; ren ew al ref used ; sp ecial co n d it io n s im p o sed ; excess im p o sed ; o r claim reject ed? Yes No Please p rovid e d et ails o f yo ur cur ren t p rof essio n al in d em n it y co verage: Cur ren t in surer : Exp iry d at e: Lim it o f in d em n it y: $ Excess: $ Prem ium : $

5 Claims history Has an y p ar t n er, p rin cip al, d irect o r o r st af f m em b er ever b een t h e sub ject o f d iscip lin ary p roceed in gs f o r p rof essio n al m isco n d uct? Yes No Have an y claim s ever b een m ad e again st yo u, yo ur p red ecesso r s in b usin ess, o r an y p resen t o r f o rm er p art n er, p rin cip al, d irect o r o r em p lo yee o f t h e b usin ess? Yes No If a curren t lo ss sum m ar y is availab le f rom yo ur p resen t an d p ast in surer s p lease at t ach a co p y. If Yes, p lease p rovid e t h e f o llo w in g d et ails in resp ect t o each m at t er: Amount paid or Is matter Date matter Name of insurer Brief details of estimate of finished or notified (if any) each matter potential liability outstanding? Are yo u, o r an y p ar t n er, p rin cip al, d irect o r o r em p lo yee, after enquiry, aw are o f an y claim s o r circum st an ces w h ich m igh t result in claim s again st yo u o r yo ur p red ecesso rs in b usin ess o r an y p resen t o r f o rm er p art n er, p rin cip al, d irect o r o r em p lo yee o f t h e b usin ess? Yes No If Yes, p lease p rovid e t h e f o llo w in g d et ails in resp ect t o each m at t er: Name of claimant or potential claimant Brief description of claim/circumstances Estimate of potential liability

6 Cover required Lim it of ind em nit y r eq uired : $ $ $ Level of excess r eq uired : $ $ $ Op t ional ext ension: Do you r eq uir e cover f or p ar t ners, d ir ect ors or p r incip al s p revious b usiness? Yes No If Yes, p lease p r ovid e t he f ollow ing d et ails in resp ect of each p art ner, p r incip al and d ir ect or : Name Names of previous firms Details of any claims made against previous firms Declaration On b ehalf of all p r op osed Insur ed s I/We d eclar e an d agr ee t hat : a) all inf or m at ion p r ovid ed, in t his p r op osal or at t achm ent s, is t r ue and com p let e in ever y r esp ect and t hat no Mat er ial Fact s rem ain und isclosed ; b) if t his r isk is accep t ed, such inf or m at ion w ill b e incor p or at ed int o and f or m t he b asis of t he cont r act of insurance; c) I/We und er st and t hat Int ernat ional Und er w rit ing Agencies req uir es t his inf or m at ion in or d er t o evaluat e t his p r op osal and t hat t he Pr ivacy Act 1993 ent it les m e/us t o have access t o, and r eq uest t he cor r ect ion of, any inf or m at ion r et ained ; d ) Int er nat ional Und erw r it ing Agencies is aut hor ised t o d isclose inf or m at ion t o it s ad viser s, r einsurers, ot her insurer s and p art ies w it h a f inancial int erest in t he sub ject m at t er of t his p r op osal; e) Int er nat ional Und erw r it ing Agencies is aut hor ised t o check d et ails against t he Insur ance Claim s Regist er and t o p lace inf or m at ion on t he Insurance Claim s regist er w hich ot her insur ers can access; f) Int er nat ional Und erw r it ing Agencies is aut hor ised t o ob t ain f r om ot her p ar t ies any inf or m at ion w hich m ay b e r elevant t o t he accep t ance of t his r isk; g) The signing of t his p r op osal d oes not b ind eit her p art y t o com p let e t he cont r act and t hat no cover w ill b e in f or ce unt il conf ir m ed b y Int er nat ional Und er w r it ing Agencies. Insur ed (s) signat ur e: Tit le: Dat e:

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