Professional indemnity insurance Design & construct proposal form

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1 Professional indemnity insurance Design & construct proposal form Instructions Please provide a full answer to every question. Please ensure that all answers are typewritten or printed in block letters within the spaces provided. A principal of the practice must sign and date this form and any separate sheets. 1 Name and address details Practice name (include all names under which you practice) Main office address Telephone number Postcode: Contact address Employer s Reference Number (ERN) (found on PAYE documents) Practice website Date established List number of branch offices Please list on a separate sheet all branch offices including addresses for which you are seeking cover. 2 The firm Please advise the following (including details of sole practitioner). Name of all Partners / Directors / Members Age Qualifications Date Qualified How long as Partner / Director/ Member of the Firm(s) 3 Staff Please advise number of permanent staff (excluding Partners, Directors, Members) Qualified Architects, Engineers, Surveyors 4 Activities Technical Staff All Other Staff Please provide full details of activities undertaken by your business and of any intended changes to these. (If you have a brochure detailing operations, please forward a copy) Bluefin Professions Design & construct v2.0

2 5 Contracts 5.1 Please provide details of the five largest contracts (in terms of total project value) Undertaken in the last five years where you had responsibility for design or other professional services: Year Client Contract Value Total Project Value Description of your Activities 5.1 Please provide details of the three largest contracts (in terms of total project value) expected to commence in the next 12 months where you have responsibility for design or other professional services: Client Your Contract Value Total Project Value Description of your Activities 6 Turnover Please split your turnover into the following categories: Previous Year Last Year Estimated for the Current Year % of total where you are responsible for the design or other professional services and these activities were undertaken by your own partners, directors, members or employees % of total where you are responsible for the design or other professional services and these activities were undertaken by professionals appointed by you or on your behalf % of total where you have no responsibility for the design or other professional services i.e. you work to the designs of, and under the supervision of, professionals appointed by the client or main contractor. 4. All other income, please specify If income is disclosed under point 1 please provide a copy of the C.V for each partner/director/member/employee who undertakes design or other professional activities, together with a full description of the actual activities that they undertake. Financial Year End Date If any turnover is derived from work carried out in connection with any overseas contract, please provide full details:

3 7 Area of practice 1. Manufacturing Plant 2. Power Plant 3. Sewerage & Water Schemes 4. Petrochemical & Refineries 5. Roads, Bridges, Tunnels & Dams 6. Harbours & Jetties 7. Mines & Associated Works 8. Swimming Pools If the answer to any part of question 8 is, please provide full details on a separate sheet 8 Fees Please state fees paid to professionals appointed by you to undertake design or other professional services during the last year split into the following disciplines Total fees paid 1 Architectural % 2 Structural Engineering % 3 Heating & Ventilation Engineering % 4 Electrical Engineering % 5 Mechanical Engineering % 6 Civil Engineering % 7 Soil Engineering % 8 Other, please specify: - % Total of % Is the above split typical of the figures for the last five years? If, please give details on a separate sheet 9 Overseas work Do you carry out work outside of the UK? If, please provide details on a separate sheet. 10 Consortiums Have you ever undertaken a contract as a member of a Consortium or joint venture? If, please provide details on a separate sheet. 11 PFI / PPP projects Have you ever undertaken a contract which forms part of a PFI or PPP project? If, please provide details on a separate sheet. 12 vation / legal agreements Do you ever accept liability for professionals appointed by others by way of novation or other legal agreement? If, please provide details on a separate sheet. 13 Consultants PI Do you now, and have you in the past, always ensured that any consultants appointed by you or on your behalf hold Professional Indemnity Insurance with a limit of indemnity at least equal to that held by you? If, please provide details on a separate sheet.

4 14 Contract techniques / practices Do all your contracts involve well-established techniques and practices? If, please provide details on a separate sheet. 15 Claims and circumstances Has any claim ever been brought against you or any past or present director/partner/principal in connection with the performance of any design or other professional services for which you were contractually or otherwise legally responsible, or has anyone threatened to bring such a claim? If, please provide full details. Are you aware of any matters, which could lead to a claim against you? This includes: 1. Any shortcoming in your work or that of a sub-contractor, or any dispute in connection with a contract, which could lead to a claim or criminal proceedings being made against you. 2. Any criticism directly or indirectly related to design or other professional services even though regarded by you as unjustifiable. 3. Any circumstances which exist that could have a detrimental effect on your satisfactory performance of your responsibilities under a contract. If, please provide full details. (Continue on a separate sheet where necessary) 16 Previous insurance Has any insurer ever cancelled, declined, refused to renew or required an increased rate or special conditions in respect of the insurance to which this Proposal relates covering the liabilities and/or activities of any past or present Partner / Director / Member / Principal? If, please provide full details. 17 Quotation requirements Please give details of the firm s current Professional Indemnity Insurance. Do not complete this question if you are already a client of Bluefin Limit of Indemnity Excess Premium Name of Insurer Renewal Date Please advise your requirements Option 1 Option 2 Option 3 Limit of Indemnity Excess

5 Confirmation Disclosure of material facts It is essential that every Proposer or Insured when seeking a quotation, taking out or renewing an insurance, reveals to the prospective Insurers any material facts or information (including any material circumstances or change in circumstance) which might influence the judgement of Insurers in fixing the premium or in determining whether they will accept the risk. Failure to do so may render the contract of insurance voidable from inception at the option of the Insurers and enable them to repudiate liability thereunder. If you have any doubt as to what constitutes a material fact or circumstance, seek our advice. I declare that the above statements and particulars are true, full enquiry having been made, and I have not omitted, suppressed or misstated any material facts and undertake to inform the Insurer of any change to any material fact. I understand that the information provided will be used by the insurers and/or their agents to arrange and administer the insurance and in handling claims which may necessitate sharing information with third parties and that information may be shared with business partners to deliver any additional services provided with this insurance. I further agree that this declaration, together with any other information provided shall be the basis of any contract between me and the Insurer. A copy of this proposal should be retained by you for your own records This form must be signed by a principal of the firm Signature: Date: Print name: Position: Please return this application form along with any other supplementary information sheets to the address detailed below:- Bluefin Professions Castlemead Lower Castle Street Bristol BS1 3AG t: f: e: Bluefin Professions is a trading name of Bluefin Insurance Services Limited which is authorised and regulated by the Financial Conduct Authority. Registered Office: 5 Old Broad Street, London EC2N 1AD. Registered in England : Bluefin Insurance Services Limited

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