MARKETFORM : SYNDICATE 2468 PROPOSAL FORM FOR DESIGN CONSULTANTS PROFESSIONAL INDEMNITY INSURANCE

Transcription

1 MARKETFORM : SYNDICATE 2468 BROKER / INSURANCE AGENT PROPOSAL FORM FOR DESIGN CONSULTANTS PROFESSIONAL INDEMNITY INSURANCE PLEASE READ THESE GUIDANCE NOTES BEFORE COMPLETING THE PROPOSAL FORM. WHERE FURTHER INFORMATION IS REQUIRED PLEASE REFER TO YOUR BROKER / INSURANCE AGENT. PLEASE NOTE THIS Proposal Form is used for indemnification on a CLAIMS MADE BASIS. This policy only responds to Claims made against the Proposer and notified to Underwriters during the period of insurance. This proposal must be typed, or completed in ink and signed and dated by such person (The Proposer) who must be of legal capacity and authorised by the Proposer to seek a quotation for Professional Indemnity Insurance and any additional coverage that may be provided by the Underwriters. Please answer every question fully, and state NIL or NONE as applicable. Incomplete answers may not be accepted and can delay quotation. Please submit, with the proposal, all relevant information including Financial Report and Accounts, Brochures etc. Should there be insufficient room in the Proposal Form for full details, please attach further information on signed and dated sheets, wherever possible following the same format and paragraph number. It is the duty of the Proposer to disclose all material facts to Underwriters. Where this is omitted, the Underwriters may avoid their obligation under the Policy. For the purpose of the Proposal and for all purposes relating to any policy issued pursuant to this Proposal, a material fact shall be deemed to be one that would be likely to influence an Underwriters judgement and acceptance of your Proposal. Upon acceptance of the Underwriters terms and conditions and payment of the premium, all information provided by the Proposer together with the guidance notes will be deemed to be incorporated in the contract between Underwriters and the Proposer Copies of the Proposal Forms should be retained for your own records SIGNING OF THIS PROPOSAL FORM DOES NOT BIND THE PROPOSER OR UNDERWRITERS TO COMPLETE A CONTRACT OF INSURANCE NOTICE TO THE PROPOSER If the Proposer of this Contract of Insurance is a resident of the EU, the parties completing this Contract are free to choose the law applicable to this Contract. However, unless it is specifically agreed to the contrary, the Contract shall be subject to the law of the Country stipulated in the applicable EC Insurances precontractually required in accordance with the Third EU Non-Life Directive. 8 Lloyds Avenue, London, EC3N 3EL. Tel No. +44 (0) Fax +44 (0) Lloyd s Extension 4352 INTERNET [email protected]

2 1 1.1: Full name of the Proposer. 1.2: Head office address 2 Names of other parties to be included:- Equity Interest Reason for Name of Main Proposer Inclusion*. *e.g. Subsidiary/management control/joint venture partner etc 3 Date Proposer established; :Has any change by way of merger, take-over or change of name occurred in the last 10 years? If 'yes' please give details with relevant dates:- 4.2:Is the Proposer financially associated with any other firm, other than in reply to question 4.1 above? If 'yes' please give details with relevant dates:-

3 5. Partners and Officers Qualification Date Qualified Time with Proposer 6. Please state number of employees Partners / Directors Architects / Engineers Surveyors I.T. Draftsmen Administration Others Total 7 Previous 12 Months Projected 12 Months 7.1 Total Gross Fees (This should include amounts in 7.2 and 7.4 only.) 7.2 Overseas Fees, Excl U.S.A 7.3 Fees for Projects in U.S.A 7.4 Fees paid to subconsultants 7.5 Fees separately insured (Please provide details of insurance cover.) 7.6 Total Construction Values What are the contract values for projects in where the insured have issued Practical Completion Certificates?

4 8 Please indicate percentage of fees derived from the following % Last % Anticipated 12 Months next 12 Months 8.1 Structural Engineering 8.2 Civil Engineering 8.3 Chemical Engineering 8.4 Mechanical Engineering 8.5 Electrical Engineering 8.6 H.V.A.C. 8.7 Soil and Geotechnical, 8.8 Project Management 8.9 Project co-ordination 8.10 Construction Management 8.11 Planning Supervision` 8.12 Architecture 8.13 Interior Design 8.14 Landscape Architecture 8.15 Material Testing & Inspection Services 8.16 Quantity Surveying 8.17 Building Surveying 8.18 Environmental / Pollution Testing 8.19 Other (describe) Totals 100% % of Work not resulting in construction % of work involving both design and inspection

5 9 Please indicate percentage of last year s fees derived from the following areas: Bridges / Flyovers % 9.2. Roads and Highways % 9.3. Water / Sewerage Schemes % 9.4. Chemical / Petro Chemical / Refineries % 9.5. Oil / Gas rigs % 9.6. Nuclear / Atomic Projects % 9.7. Mechanical / Manufacturing Plant % 9.8. Residential Buildings % 9.9. Commercial Buildings % Hospitals / Universities / Schools % High Rise Buildings (10 storeys or more) % Factories / Warehouses % Harbours /Jetties / Sea Defences % Tunnels / Dams % Mining /Shaft sinking % Landfill / Land Reclamation % Piling / Foundations % Others (please specify) % : Does the Proposer belong to any Trade Associations or Professional bodies? If "Yes", please identify. 10.2: Has the Proposer achieved ISO qualification, Quality Assurance or similar? If "Yes", please identify Does the Proposer construct, manufacture or provide advice, design or services for or in connection with prototypes or innovative designs or products? If "Yes, please provide details Does the Proposer supply or manufacture any goods or materials in connection with any work? If "Yes, please provide details Does the Proposer engage in any actual construction, fabrication or erection? If "Yes, please provide details Please provide the following information regarding the five largest contracts, relevant to the proposed insurance, in recent years: Name of Client Description of Contract Contract Value Fee

6 12.2 Is there any major change in the nature of projects anticipated in the next 12 months? If "Yes, please provide details. 13. Please list the countries in which any advice, design or services declared under Question 7.2. are offered and state the approximate income for each country : Are full rights of recourse maintained against sub-contractors, consultants and product suppliers? If "No" please provide details 14.2: Does the Proposer ensure that sub-contractors,consultants or product suppliers maintain their own Professional Indemnity insurance? 15. Does the Proposer always: 15.1: effect a written contract with your client before the advice, design or services are provided? 15.2: obtain legal advice before contracts are signed? 15.3: exclude liability for consequential loss? If "No" to any of the above please provide details: PREVIOUS INSURANCE HISTORY 16. Has the Proposer previously insured for professional indemnity? If "Yes", please provide the:

7 16.1: Name of insurers Date the Policy expires: 16.2: Indemnity Limit: Excess 16.3: Basis of cover ( claims made or losses occurring) 16.4: Retroactive Date 17. Has any insurer ever: 17.1: Declined a proposal or a renewal for this insurance? 17.2: Imposed special terms or increased premiums other than standard market increases? 17.3: Cancelled the insurance? If "Yes", to any of the above please provide details: : Please state amount of indemnity required; 18.2: Please state amount of Excess the Proposer is willing to carry, if available, as uninsured of each and every claim ( which includes associated Defense Costs ) PREVIOUS CLAIMS HISTORY : Has any claim that would have been covered by the proposed insurance ever been made against the Proposer or any of its directors or employees during the last 10 years? If "Yes", please provide details including the amount claimed: 19.2: Has the Proposer been involved in any dispute or arbitration concerning professional fees, advice or services to others during the last 10 years? If "Yes", please provide details: 20 Do any of the directors or employees, AFTER ENQUIRY, have any grounds for suspecting, or are they aware of any circumstances which might give rise to a claim against the Proposer or against any of the present or former directors during the last 10 years?

8 If "Yes", please provide details including the potential costs: DECLARATION I/We declare and warrant that after enquiry all statements and particulars contained in this proposal and addenda are true and that no information whatsoever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this proposal and should the above particulars alter in any way I/We will advise Underwriters as soon as practicable. I/We understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of the proposal may result in the Underwriters refusing to provide indemnity or voiding the policy in every respect. I/We hereby agree and accept that this Declaration shall be the basis of the contract between me/us and Underwriters upon acceptance by me/us and of the quotation afforded by Underwriters. Signed on behalf of Proposer.Name. Position.. Date / /.