PROFESSIONAL INDEMNITY INSURANCE

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1 BDB (UK) Limited 40 Lime Street, London EC3M 7AW PROFESSIONAL INDEMNITY INSURANCE ACCOUNTANTS PROPOSAL FORM 1

2 GUIDANCE NOTES This proposal must be completed in ink by a Partner or Director of the Proposer. Please use your headed notepaper to provide full answers. Please enclose your Company brochure (if applicable). Note, you must fully disclose all material facts. Failure to do so may result in voidance of the policy and/or repudiation of liability. A material fact is one which influences the Insurer s assessment of the risk. If you have any doubt whether something is a material fact, disclose it. The completion and signature of this form does not bind either the Proposer or the Insurer to complete a contract of insurance. Please retain a copy of the form for your records. 2

3 1 Name(s) under which business is conducted 2 Date of establishment 3 Principal Address/Website Address 4 (a) Has the name of the business changed or have any mergers or acquisitions taken place during the past five years? (b) Is cover required for the above predecessor firms? 5 Is cover required in respect of the liability of any Partner or Director arising out of advice given or services performed prior to joining the Firm(s)? If YES, please advise: (a) Name of Partner(s) or Director(s) (b) Name of Previous Firm(s) (c) Applicable Date(s) 3

4 6 Give details of all partners/directors Name Age Qualifications Date Qualified How Long Practising as a Partner/Director IF UNDER FIVE YEARS EXPERIENCE IN THIS OCCUPATION PLEASE SUPPLY A CURRICULUM VITAE 7 Please state number of other staff 8 Is cover required for any Independent Accountant to whom work is or has been subcontracted? If YES, please state: Name Qualifications Fees Paid Last Financial Year Does Accountant have own PI cover? 9 a) Please advise the date of your Financial Year end b) Please state the total gross commission/fee income for: PAST YEAR ENDED CURRENT YEAR ENDING FORTHCOMING YEAR c) Please state the largest total fee from any one client or group 4

5 10 Please specify the gross fees derived from the following: (a) Audit, Accountancy and Company Tax (i) Listed Public Companies (ii) Unquoted Companies and others (including farmers, small traders, etc other than listed PLC s) (iii) Banks, Financial Institutions, Insurance Companies, Underwriting Agencies or Offshore Companies (b) Management Consultancy (c) Insolvencies, Liquidations and Receiverships (d) Directorships (e) Taxation (f) Insurance Commissions (non-life and non-pensions business) (g) Life Assurance, Pensions Advice, Commissions/Brokerage (h) Investment Advice (see below) (i) Any other (please specify below) United Kingdom % USA/ Canada % Elsewhere % Please specify the other activities where applicable Investment Advice - If authorised for investment business please state the name of the professional body granting such authorisation and set out below they type(s) of investment business for which authorised NB For any of the above types of work where you have answered nil please give details if you have been engaged in such activities in the last 6 years 5

6 11 Do you envisage any material changes in the activities as described above in the next twelve months? If YES please give details:- 12 (a) Has the business sustained any loss during the past six years as a result of the fraud or dishonesty of any partner, director or employee of the business? (b) Is any individual authorised to sign cheques as a sole signatory on behalf of either the business or clients accounts?, specifying limit (c) How often are entries in cash books reconciled with bank statements by a partner/director or company secretary (other than the head cashier and/or chief bookkeeper)? Weekly Monthly Quarterly (d) (e) Is there a complete annual audit by a firm of professional accountants? Are clients funds kept in properly designated clients accounts separate from the accounts of the business? 13 Please give details of the firm s current professional indemnity insurance Limit of Indemnity Excess Premium Name of Insurer Expiry Date 6

7 14 (a) What limit of indemnity is required? (b) What excess do you wish to carry? 15 In respect of professional indemnity insurance, has any insurer ever declined a proposal, declined to pay a claim, refused renewal, cancelled such insurance or imposed special conditions? 16 Claims History (a) Has any claim been made against the business or an employee of the business or any partner, director or consultant or their predecessors in business during the last six years in respect of the type of liabilities to which this proposal relates? Date of Claim Brief Details Amount Paid Reserves Outstanding (b) Has any action been taken to prevent a recurrence of a claim? 7

8 (c) After enquiry, are any of the business partners or directors aware of any claim pending or any circumstance which might give rise to a claim against the business or any of the present or previous partners or directors of the business? IMPORTANT REMINDER: ALL CLAIMS/COMPLAINTS AND CIRCUMSTANCES (i.e. POTENTIAL CLAIMS) MUST BE IMMEDIATELY REPORTED TO YOUR EXISTING INSURER PRIOR TO EXPIRY OF YOUR CURRENT POLICY. Please advise any matters or circumstances which we might wish to take into account in determining whether to offer you insurance cover DECLARATION I/We declare that the above statements and particulars are true, full enquiry having been made and I/We have not suppressed or mis-stated any material facts and undertake to inform the Insurer of any change to any material fact I/We agree that this declaration together with any other information shall be the basis of any contract between me/us and the Insurer SIGNATURE OF PROPOSER (PARTNER/DIRECTOR) NAME FOR AND ON BEHALF OF DATE (Insert Name of Business/Firm) Please retain a copy of this completed proposal form for your records 8

9 ACCOUNTANTS SUPPLEMENTARY QUESTIONNAIRE 9

10 1 Please list all Self Employed individuals to whom work is sub-contracted and for whom cover is required 2 Do you sub-contract work to any other Firm or Company? If YES, please supply full details NB: The fee income earned by Sub-Contractors named in 1 and 2 above should be declared as part of the income of the Firm 3 Has any work been carried out: (a) In the United States of America or Canada? (b) Elsewhere Overseas? If YES, please specify the area(s) concerned, the nature of work and the fee income derived therefrom 4 Have you or any person for whom insurance is sought, ever been the subject to disciplinary proceedings by the ICA or any other professional organisation of which you are or have been a member? 5 Have you received a visit from the ICA Joint Monitoring Unit or equivalent monitoring unit from your professional organisation? 10

11 6 Has the firm undertaken any Administrations or Receiverships since 1987? YES If YES, please answer the following in relation to each appointment NO (a) Did the Company continue to trade after your appointment, and if so, for how long? (b) Were the employees/directors dismissed within 14 days? If NO (i) Was the company sold as a going concern? (ii) Are there any funds available to meet any possible claims? (iii) Are there indemnities available, e.g. from debenture holders? (iv) Were there any highly paid employees or directors? NAME OF FIRM(S) SIGNED BY PARTNER DATE 11

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