PROFESSIONAL INDEMNITY PROPOSAL FORM

Transcription

1 AAO Pana Insurance Brokers Sdn Bhd 29-1, Dataran Prima Business Centre, Jalan PJU 1/41, Petaling Jaya Tel : Fax : Web site : PROFESSIONAL INDEMNITY PROPOSAL FO LAWYERS IMPORTANT NOTICE Pursuant to Section 149(4) of the Insurance Act 1996, you are to disclose in this proposal form, fully and faithfully all the facts which you know or ought to know, otherwise you could prejudice your rights to recover in the event of a claim or allow the Insurer to void the Policy. GENERAL INFOATION 1. Name of Practice 2. Address of Practice (If more than one, please state every address and indicate principal or partner responsible at each address) 3. Date of Commencement of Practice 4. Has the name of the Practice been changed, any other business purchased or any merger or consolidation taken place during the YES NO past five years? 5. What professional association, if any, does the Practice belong to? 6. What are the dates of the financial year of the Practice? From To 7. What are the gross fees for : a) 12 months prior (audited) b) 12 months expiring c) Estimate for next 12 months Please explain any substantial variation in consecutive years. Page 1 of 7

2 8. Does the business of the Practice extend to or has it ever been extended to activities in foreign countries? YES NO If YES, please indicate the approximate percentage of gross fees derived: a) from domestic activities % b) from foreign activities % Total: 100% c) Name the foreign countries d) State method of handling such business 9. Indicate the approximate percentage of gross fees derived from the Approximate percentage following activities: (if none, state "NONE") a) Real Estate Conveyancing % b) Litigation % c) Estate work % d) Commercial matters % e) Divorce % f) Corporate % g) Patents % h) Any others (please give details) % Total: 100% PERSONNEL 10. Practising Partners or Principals Name Qualification & How long practising in Date Qualified this Practice 11. Former, retired or deceased Partners: Name Date of Joining this Practice Date of leaving this Practice Page 2 of 7

3 12. Total number of practising Partners, Principals and staff Permanent Temporary a) Partners or Principals b) Other equally qualified professionals c) Staff other than typists, telephonists, receptionists, office boys and messengers d) Typists, telephonists, receptionists, office boys and messengers Total 13. Has any of those listed in question (10) ever been subject to disciplinary action by the authorities as a result of their YES NO professional activities? INSURANCE REQUIREMENTS 14. Specify the Limit of Indemnity required (Give alternatives if required) 15. What amount of Excess would the Practice would be prepared to carry in respect of each claim? (A minimum excess is required depending on the size of firm and indemnity limit selected) 16. Does the Practice require indemnity of any or all of the following extensions for which extra premium is required? 16.1 Retroactive Cover Extension Do you require this extension? YES NO Retroactive date requried 16.2 Partners' Previous Business Extension Do you require insurance for partners? a) Incoming partners YES NO b) Outgoing partners YES NO If YES, please give names of those for whom insurance is required Name Date of joining / leaving firm Period of cover required Page 3 of 7

4 16.3 Loss of Documents Extension Do you require this extension? YES NO If YES, do you keep documents in fire-proof cabinets / safes? YES NO Please describe storage if other than fire-proof cabinets / safes. What limit of cover as a percentage of the total limit insured 10% 20% do you require? 50% 100% 16.4 Libel and Slander Extension Do you require this extension? YES NO If YES, please give details of claim(s) made against your firm involving libel & slander What limit of cover as a percentage of the total limit insured 10% 20% do you require? Page 4 of 7

5 16.5 Dishonesty of Partners and Employees Extension Do you require this extension? - for partners YES NO - for employees YES NO If YES, please answer the following: a) Has the firm sustained any loss through fraud or dishonesty YES NO of any partner or employee? b) Does the firm know of any fraud or dishonesty at any time of YES NO any present or former partner or employee? c) Does the firm always obtain satisfactory reference when YES NO engaging employees? d) Are any employees allowed to sign cheques without YES NO counter signature by a partner? If answer to d) is YES, up to what amount? e) Are cheques signed by the sole proprietor / partners pre-franked YES NO i.e. the amount in words and in figures duly made out in the cheques prior to signing? f) At what intervals are your clients' accounts audited? g) Who are your accountants? h) Who are your auditors? If YES to question a) and/or b), please give details: Page 5 of 7

6 PREVIOUS COVERAGE 17.1 Has the Practice in the past been insured for professional liability risks? If YES, please state: YES NO a) Date of previous insurance b) Name of previous insurers c) Excess borne by firm d) Amount of indemnity e) Expiry date of policy 17.2 Is the Practice at present insured for professional liability risks? If YES, please state: YES NO a) Name of insurer b) Excess borne by firm c) Amount of indemnity d) Expiry date of policy e) Premium paid 18. Has any application for insurance on behalf of the Practice or its predecessors in business or any of the present Partners or YES NO Principals been declined or has any such insurance been cancelled or renewal refused or have special terms been imposed? 19. Has any claim been made against or allegation of negligence been made against the Practice or its predecessors in business YES NO or any of the present or former Partners or Principals? If YES, state briefly the cause and nature of claim including the amount involved and names of the partner and the claimant, the date the claim was made, the date of the act giving rise to the claim, and the final disposition. 20. Are the Partners or Principals, after enquiry, aware of any circumstances which may result in any claim being made against YES NO the firm, its predecessors in business or any of its present or former partners or principals? Page 6 of 7

7 SUPPLEMENTARY QUESTIONS ON EXCESS LAYER 21 Does the firm always use Letter of of Engagement / Letter of Instruction in confirming and detailing the scope of all representations? YES NO 22 Does the firm always use Letter of of Engagement / Letter of Instruction in confirming fees or billing rates for all representations? YES NO 23 Does the firm always confirm in writing when declining to represent or accepting a matter? YES NO 24 Does the firm maintain a Calender / Docket Control System for all litigation and non-litigation matters? YES NO 25 Please describe the firm's system of avoiding missed deadlines and due dates. 26 Does the firm maintain a conflict of interest avoidance system? YES NO 27 Does the firm disclose in writing any conflict of interest? YES NO 28 Does the firm obtain the written consent from each client represented after disclosing a potential conflict of interest? YES NO 29 Has the firm acted as an adviser in any Merger or Acquisition within the past five years? If YES please provide the names of the parties whom the firm represented and the transaction value YES NO 30 Has the firm acted as an adviser in any Public Offering within the past five years? If YES please provide the names of the parties represented and the transaction value. YES NO 31 Has the firm acted as an adviser in any Global or American Depository Receipt YES NO Offering within the past five years? If YES please provide the names of the parties represented and the transaction value. 32 Is there any partner or lawyer in the firm who is a director or company secretary for another company? If YES, please state the name of the other company, the nature of the appointment, the primary operation of the other company, and whether the other company is also a client of the firm. Declaration 21. I/We declare that the statements and particulars in this Proposal are true and that I/we have not misstated or suppressed any material facts. I/We agree that this Proposal, together with any other information supplied by me/us shall form the basis of any contract effected thereon. I/We undertake to inform the Insurer of any material alteration to these facts whether occurring before or after completion of the contract of insurance. For and on behalf of Insert name of Firm / Organisation Signature of Principal / Partner Dated Page 7 of 7