PROFESSIONAL INDEMNITY PROPOSAL FORM

Transcription

1 PROFESSIONAL INDEMNITY PROPOSAL FORM For the Design and Consulting Department of Electrical and Mechanical Services Contractors Please answer all questions. It is appreciated that for some Proposers, certain questions may be inapplicable and in such cases the fullest possible alternative information is required. This proposal must be completed in ink by a Director or Partner of the Proposer. The completion and signature of this Proposal does not bind the Proposer or Insurers to complete a Contract of Insurance. If there is insufficient space to answer questions, please use an additional sheet and attach it to this form. Please attach any brochures on your activities. Proposer s Full Name Include all companies to be insured If the Proposer is not a limited company specify any trading names and the names of all principals and partners. Address If more than one, please give each address and specify which is your head office. Tel Fax Post Code 1. When was the business established? 2. Are you financially associated with any other business? YES NO 3. During the past 5 years has the name of the business been changed or has any other business been purchased or any merger or consolidation taken place? YES NO If YES to either Question 2 or 3 above, please provide full details: 4. Are you a) a member of a trade body or association? YES NO b) accredited or registered with an approvals or certification body in respect of the work you undertake? YES NO If YES, please provide details including your membership/registration number(s): UW/2013/07/11 Page 1 of 8

2 5. About your Design and Consulting Department a) Design & Consulting Department Staff Details: Names of principals and senior members of staff Title of position and length of time as such Qualifications and dates qualified b) Design & Consulting Department Staff Numbers: Principal and senior qualified members as listed in a) above: Other technical and qualified staff: Clerical, Typists and others: Total c) Are any of your Design or Consulting staff based outside of the United Kingdom? YES NO d) Do you use independent specialist consultants or sub-contractors? YES NO If YES to d) above, do these consultants/sub-contractors have their own adequate insurance arrangements in place? YES NO e) Are any persons ever hired from outside agencies on a short-term basis to assist the Design and Consulting Department? YES NO If YES to either 5 c), 5 d) or 5 e) above, please give details: 6. Please give an approximate percentage split of the disciplines within your Design and Consulting Department: Electrical Engineering % Heating & Ventilation Engineering % Air Conditioning Engineering % Mechanical Engineering % Instrumentation (Electrical) % Plumbing % Instrumentation (Pneumatic) % Other (Please Specify) % Total 100% UW/2013/07/11 Page 1 of 8

3 7. a) Indicate as a percentage of total work the extent of the following activities: Design & Consult Only Design & Install Home Building Individual Dwellings: % % Multiple Dwellings Low Rise % % High Rise % % Modular Dwellings % % (i.e. involving repetitive design) Industrial Power Plants % % Refinery & Petro-Chemical Installations % % Manufacturing Plant & Production Areas % % Industrial Building Systems (i.e. modular involving repetitive design) % % Other Industrial % % Please Specify: Commercial Amenities Hospitals & Nursing Homes % % Schools & Universities % % Hotels & Recreation Centres % % Shops & Offices % % Other Commercial % % Please Specify: Specialist Installations Installations within a computer environment % % Burglar Alarm Installations % % Other Specialist Installations % % Please Specify: Maintenance Contracts % Inspection of Existing Systems % Where specialist installations are undertaken, please supply details of your company's experience in undertaking such activities, together with an appropriate CV of the person nominated in question 6 a) by the Firm as being responsible for such activities. Please also specify whether your company is a member of or approved by specialist industry groups, such as the National Approval Council for Security Systems, or the Electrical Contractors' Association Security Group. b) Does the design work carried out by or on behalf of your business solely consist of well-established techniques? YES NO If No to b) above, please provide full details: Page 3 of 8

4 c) Have you ever failed to complete a project? YES NO If YES to c) above, please provide full details: d) Have you undertaken, or do you undertake, any contract involving the operation or safety of railway rolling stock or any railway system, aircraft or any aviation system, ships, boats or other seagoing vessels? YES NO IF YES to d) above, please provide full details: Note: ECIC s standard policy excludes cover for such work. If you intend to perform any contract related to this work you should provide full details to ECIC before commencing any contract to enable us to consider any requests for cover. e) Please complete the following table (tick appropriate box) with reference to current activities where you contract on a Design & Build basis. Please ignore work undertaken as a pure installation only contractor. Nature of Work Your Design Activity Your Design Capability Lighting Installations Power Installations Emergency Lighting Fire Alarm Systems Security/CCTV Building Management Sys. Computer/IT Networks Data Cabling Fibre Optics Control Systems Power Factor Correction Broadcast Facilities Motor Rewinds HV Jointing Industrial Installations>36kv Street Lighting Underground Cabling Hazardous Areas Mechanical Services Air Conditioning Heating Ventilation Plumbing High Some None Sub Cont Out Full Some None Page 4 of 8

5 8. a) What was your Total Gross Turnover for the last three financial years? Last Year One Year Ago Two Years Ago b) Please state Month of Financial Year End: 9. Please give details of your turnover, in 000s: a) i Turnover where you Design & Install from your own Design & provide full technical supervision ii Turnover where you accept full design responsibility but sub-contract both Design & Installation to bona fide sub-contractors b) Turnover of those departments where you provide Design & Technical Services but are not involved in Installation c) Turnover where you provide Installation services only having engaged others to provide Design & Technical Supervision on your behalf d) Turnover where you provide Installation services only having been provided with a Design & specification by your Principal or your Principal s agents (Pure Contracting Activity) e) Turnover where you provide Maintenance Services including Technical services Last 12 Months Next 12 Months f) Turnover where you provide Inspection, Testing or Certification Services (including PAT) g) Other Turnover not mentioned above Total Turnover: Please specify the nature of any turnover given against 9 g) above: Does this turnover involve design responsibility for the business? YES NO 10. a) Please give details of the five largest contracts commenced during the last 5 years where the Design and Consulting Department has been involved: Date Started Name & Type of Project Services Performed Total Contract Value Completion Date Page 5 of 8

6 b) Please give details of any major new operations being undertaken during the next 12 Months: c) Does any client or contract represent more than 50% of annual work? YES NO d) Do you engage in any overseas operations? YES NO If YES to either c) or d) above, please provide full details: 11. Please give details of existing Professional Indemnity insurance: If none, state None : Name of Insurers: Indemnity Limit: Excess: Date of expiry of coverage: Retroactive Date: Annual Premium: 12. a) Please advise the Limit of Indemnity you require: Note: Our standard Limit is Aggregate plus one automatic reinstatement including costs and expenses incurred in the defence or settlement of a claim. 250, ,000 1,000,000 Other (please specify): b) Please advise the amount you would be prepared to carry in respect of each claim: Note: Our minimum excess starts at 1,500 but the minimum applicable to your policy will depend on the size of your business and the work you undertake. Discount s may be available should you opt for a higher amount. 2,500 5,000 10,000 Other (please specify): 13. Your Claims and Insurance History: a) Has any Proposal for similar insurance made on behalf of the business, any predecessors in business, or present partners, ever been declined or has any such insurance ever been cancelled or renewal refused? YES NO b) Have any claims for professional negligence, error or omission been made against the business or its present Directors/Partners (whether insured or not)? YES NO c) Are any of the Directors/Partners or employees AFTER ENQUIRY, aware of any circumstances, allegations or incidents which may give rise to a claim against the business or its predecessors in business or any of its present or former Directors/Partners? YES NO If YES to either a), b) or c) above, please give details: Page 6 of 8

7 IMPORTANT Please read the following and check your answers carefully before you sign and date the Declaration. The questions on this proposal form and any other details we specifically request, relate to facts which we consider material to underwriting this insurance. However, because no list of questions can be exhaustive please consider whether there is any other material information which is known to you which could influence our assessment and acceptance of the risk. Failure to disclose all material facts whether or not the subject of a specific question may invalidate your insurance. We recommend that you should keep a record of all information, including copies of this proposal form and any letters, supplied to us for the purposes of entering into this insurance contract. Please let us know if you would like a copy of this proposal form sent to you. 1. I/We declare that to the best of my/our knowledge and belief a) the statements and particulars supplied by me/us or on my/our behalf in this proposal are true and complete b) any statements or particulars supplied by me/us or on my/our behalf separately are true and complete c) that no material information has been withheld mis-stated or suppressed. 2. I/We agree that this proposal and any statement and particulars supplied separately shall form the basis of the contract between me/us and the Electrical Contractors Insurance Company Limited. 3. I/We undertake to inform Electrical Contractors Insurance Company Limited of any material alteration to the statements particulars or material information supplied whether occurring before or after completion of the Contract of Insurance. 4. I/We agree to accept the Electrical Contractors Insurance Company Limited s usual form of policy for this type of insurance. A specimen copy of the policy is available on request. 5. I/We understand that Insurers share information with each other, credit reference agencies and other information agencies with regard to credit agreements, policies and claims, primarily to help assess risks, handle claims and prevent frauds. I/We consent to this. For and on behalf of: (insert name of Proposer) Signature of Design & Consulting Department s Principal Date Proposer s Authorised Signatory Position of Authorised Signatory Note: In the case of a Company a Director or Responsible and Identified Officer must sign this form. In the case of a Partnership, it must be signed by the Principal or Partner, and in either case by the Head of the Design & Consulting Department. Data Protection Act We may use the personal and business details you give us, or which are supplied by third parties, to provide you with a quotation, to administer your policy, to search the files of credit reference agencies who may keep a record of the search, to carry out such financial and other enquiries as we consider necessary to evaluate the risk and assist in making a decision regarding our acceptance of the risk, to support the development of our business including your details in customer surveys, and for market research and compliance business reviews. We may also share these details with other insurance organisations to help off-set risks, to help administer your policy and to handle claims and prevent fraud. We will store your details on computer but will not keep them for longer than necessary. Under the terms of the Data Protection Act 1998, you are entitled to a copy of all the information we hold about you. Page 7 of 8

8 Notice to Proposers Under the Insurance Companies (Third Insurance Directives) Regulations 1994 If you are applying for insurance protection as a private individual or as a sole trader (or for the benefit of a private individual or sole trader) you should carefully read the following information. Law Applicable to the Contract The law applicable to this insurance contract is subject to agreement between the parties. Unless a special endorsement to the contrary has been requested by you and agreed by us the law applying to this Insurance contract will be as follows: if you are applying for insurance protection as a private individual the law applicable to that part of the United Kingdom, Channel Islands or Isle of Man in which you or the first named policyholder normally resides, or if you are applying for insurance protection in your capacity as a sole trader the law applicable to that part of the United Kingdom, Channel Islands or Isle of Man in which you have your principal place of business, or if neither of the above applies, the Law of England and Wales. Electrical Contractors Insurance Company Limited (Company No ) Registered in England and Wales at ESCA House, 34 Palace Court, London W2 4HY Customer Care Electrical Contractors' Insurance Company Limited ('ECIC') is committed to maintaining a high standard of professional conduct in all our dealings with customers. However if you feel that your insurance arrangements have not been handled in the manner in which you would expect and you wish to make a complaint, please contact the Underwriting Manager at the office of ECIC that issued your policy. We will ensure that the matter receives immediate attention. You will be sent a copy of our Complaints Handling Procedure. If you feel that the matter has not been settled to your satisfaction you may write to the Managing Director, ECIC, ECA Court, South Park, Sevenoaks, Kent TN13 1DU. If you are not satisfied with our investigation and conclusion of your complaint or eight weeks have passed since initially making your complaint and you are an individual consumer or a business with a group annual turnover of less than 1million you may refer the matter to the Financial Ombudsman Service, South Quay Plaza, 183 Marsh Wall, London E14 9SR. ECIC is a member of the Association of British Insurers and a member of the General Insurance Standards Council. ECIC is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Your right as a policyholder to take legal action remains unaffected by the existence of the complaints procedures referred to above. Page 8 of 8