PROFESSIONAL INDEMNITY INSURANCE SINGLE PROJECT PROPOSAL FORM

Transcription

1 PROFESSIONAL INDEMNITY INSURANCE SINGLE PROJECT PROPOSAL FORM IMPORTANT NOTICE This proposal form must be completed in ink by the Individual or a Partner, Principal or Director of the Firm or Company. All questions must be answered to enable a quotation to be given. The completion and signature of this proposal does not bind the Proposer or Underwriters to complete a Contract of Insurance. If there is insufficient space to answer questions, please continue on your headed notepaper and attach it to this form. Please provide a Brochure, if possible, and any standard contract terms, conditions, agreements or letters of appointment which you have with your clients. 1. Name of firm(s) for which indemnity is sought: 2. When was the firm established? 3. Principal Address of Firm: Telephone No.: Facsimile No.: Other addresses by Town only: 4. a) Please supply details of your design and consulting department staff: Names of principals and senior members of staff Qualifications in full Date Qualified Title of position and length of time as such

2 b) Numbers of staff: Home Based Overseas Based Directors and senior qualified members as listed: Other technical and qualified staff: Clerical, typists, others: TOTALS c) Do you use independent specialist consultants? YES NO If YES please give full details: Do you require them to carry a minimum level of professional indemnity cover? YES NO If YES how much? d) Are any persons ever hired from outside agencies on a short term bases? YES NO If YES please give full details: 5. Please give an approximate percentage split of the disciplines with your design and consultancy department: Architectural % Chemical Engineering % Civil Engineering % Soil Engineering % Structural Engineering % Nuclear Engineering % Mechanical Engineering % Surveying - land % Electrical Engineering % - quantity % Heating and Ventilating % - building % Engineering % Others (please specify below) %

3 6. Indicate as a percentage of total work the extent of the following activities: Design only Design and Construction % % Home Building 1. Individual dwellings 2. Low rise multiple dwellings 3. High rise multiple dwellings 4. Modular dwellings (i.e. involving repetitive design) Engineering construction 1. Highways 2. Bridges, tunnels and dams 3. Railways, airports, harbours & Jetties 4. Sewage/water schemes Industrial 1. Power plants 2. Refineries & petro chemical installations 3. Manufacturing plants 4. Industrial building Systems 5. Offices/commercial properties Amenities 1. Hospitals & nursing homes 2. Schools & universities 3. Hotels & recreation centres Other or specialist construction (please specify below)

4 7. Do you engage in the manufacture or fabrication of any pre-engaged unit? YES NO If YES please give the following details: a) Add her a stated of the type of work normally carried out, whether consisting of well established techniques or the nature of new an original though developments, processed or designs employed: b) Have you ever failed to complete a project? YES NO If YES please explain the reason and type of project etc: 8. Please give details of the project for which insurance is sought 1. Title and Location of the project: 2. Legal Jurisdiction to which this insurance should respond: 3. Brief Description of the project: (please attach details): 4. Estimated Total Contract Value: 5. Estimated Gross Professional Fees (Actual or notional): 6. Commencement Date of Activity: 7. Extended Reporting Period (after expiry of policy period): 8. Please attach relevant extract of contract relating to insurance 9. Please advise the basic form of Contract under which the professional responsibilities will be performed:

5 10. Are you financially associated with any other firms? YES NO If YES please give details: 11. During the past five years, has the name of the firm been changed or has any other business been purchased or merger or consolidation taken place? YES NO If YES please give full details: 12. Has any claim been made against this firm or any director, partner, principal or senior member of the staff while in a previous firm? YES NO If YES please give full details: 13. Is the proposer aware, after full enquiry, of any circumstance or incident which has or may result in any claim being made against the firm or any of the directors, either past or present, whilst they were in the firm, or in any previous firm, or position, or any of the employees? YES NO If YES, please attach a statement giving full details: 14. What is the amount of indemnity required? 15. What is the amount of excess which your firm would be prepared to carry in respect of each claim?

6 16. Declaration It is your duty to disclose all material facts to Underwriters. A material fact is one which may influence an Underwriter's judgement in the consideration of your proposal. If you are in any doubt as to whether a fact is material you should disclose it. Failure to disclose could prejudice your rights to recover in the event of a claim or allow Underwriters to void the policy. I/We declare that the statements and particulars contained in the proposal are true and that l/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 of insurance effected thereon. I/We undertake to inform Underwriters of any material alteration to these facts occurring before completion of the contract of insurance. However, the duty to disclose material facts continues after the completion of the proposal form and throughout any period of insurance (and any extension thereto) upon which this proposal was used as the basis of the contract of insurance. Signature (Partner, Principal or Director) For and on behalf of Dated