QPI Professional Specialists in Protecting Professions Professional Indemnity Insurance Proposal Form for Accountants Short Proposal Form for 1-4 Partner Firms IMPORTANT INFORMATION Duty of Disclosure When completing any insurance proposal form it is essential that any material facts or information which might influence the judgement of insurers in fixing the premium, or in determining whether they will accept the risk is disclosed. The onus is on you to decide what may be material and there is no duty on Insurers to make enquiries of you. Failure to disclose material facts may allow insurers to avoid the policy and / or repudiate a claim under it. This duty of disclosure applies equally on taking out a new insurance policy and at renewal and throughout the duration of the policy term. Presentation of the Proposal Form It is important that the proposal form is completed as clearly as possible and the declaration signed by a Partner, Director or Principal of the firm. Failure to present the proposal form in a clear format may affect an underwriter s ability to offer terms. If completing the proposal form by hand, we recommend that you use black ink and write clearly in block capitals. All questions must be answered. If not applicable state N/A. If you run out of space please use the additional sheet provided, or alternatively use your firm s letterhead. To support your application, we recommend that where available you supply any brochures, letters of appointment and terms and conditions. Need our Advice? Should you require any advice or assistance with completing this proposal form, QPI Professional will be glad to help. Please contact us on: 01604 712222. 1 of 7
General Details 1. Name of Practice (please include all names under which you practice) Date Established Main Office Address Main Office Telephone Number Contact Name Contact Email Address Practice Website Address 2. Number of branch offices PLEASE LIST ALL BRANCH OFFICES INCLUDING ADDRESSES ON A SEPARATE SHEET WHERE COVER REQUIRED Staff and Partners 3. Please give details of all Partners, Directors or Members of the Firm (s) including if sole practitioner: Full Name Age Qualifications Date Qualified State how long as Partner/Director/Member 4. Please advise number of permanent staff (excluding Partners, Directors or Members) Qualified Full Qualified Part Other Full Qualified Part 2 of 7
Activities of the Firm 5. Please provide details of your gross fee income for the following (if this is a new firm please provide estimate for the first financial year) Last Financial Year Largest Fee from any one client Fees Paid to sub consultants 6. If the firm has fees emanating from contracts in the USA /Canada, please state contract values, nature of work and whether the work is carried out from the UK on the separate sheet provided 7. If the firm has fees emanating from contracts elsewhere, please state contract values, nature of work and whether the work is carried out from the UK on the separate sheet provided 8. Please give the approximate percentage breakdown of your last Financial Year income / fees in the following categories: 1 Audit, Accountancy & Compliance Tax % 2 Other Taxation % 3 Mergers Acquisitions and Disposals % 4 Financial Services % 5 Insolvency, Liquidations & Receiverships % 6 Corporate Finance % 7 Executorships, Directorships &Trusteeships % 8 Other Work % Total (please check 1-8 equals 100%) 100% If Other Work is carried out please give details: 9. Does the firm undertake or has the firm previously undertaken work of any description for Banks and other Financial Institutions, Insurance Companies, Lloyds Syndicates, Funds or Managing Agents (including Captive Insurance Companies), Offshore Companies, PLC s, entertainment or professional sports clients If YES, please provide details on the separate sheet provided. 3 of 7
10. Have you or any firm you have acquired, ever carried out any regulated activities as defined in the Financial Services and Markets Act 2000 (other than in connection with general insurance products) as: (a) Financial adviser; Execution only; Tied Agent or Appointed Representative? (b) Introductory agent only If you have answered YES to (a) above, a Financial Services Questionnaire will be required, please contact the QPI office to request this. If you have answered YES to (b) above please answer the following questions: (i) Do you have any financial interest or controlling interest in the company that you are introducer to? (ii) Can you confirm that gross commission/fees received in any one of the last six financial years as introductory agent did not exceed 10,000 or 10% of your total fee income? (iii) Can you confirm that you only introduce to an independent financial advisor who is authorised and regulated by FSA? Claims Information 11. After enquiry, are you aware of any claim against the Firm(s) or its predecessors in business or the present or former Partners / Directors / Principals, or any circumstances, allegations or incidents which may give rise to a claim? If YES, please give details on a separate sheet to include date of claim / circumstance, full details and confirmation of any amounts paid to insurers or outstanding. 12. Is any Partner, Director or Principal, after enquiry aware of any disciplinary actions taken towards the firm and / or Partner / Director / Principal? 13. Has the Firm(s) sustained any loss through fraud or dishonesty of any person? Is the Firm(s) aware of any allegation or occurrence of fraud or dishonesty at any time committed by any past or present Partners, Director or employee? If YES to either question, please provide details on the separate sheet provided. 4 of 7
Previous Coverage 14. Please give details below of the firm s current Professional Indemnity Insurance: (Do not complete if you are already a client of QPI Professional) Renewal Date Limit of Indemnity Premium Excess Insurer Name 15. Has an insurer ever declined a proposal, declined to pay a claim, refused renewal, cancelled the policy or imposed special conditions in respect of professional indemnity insurance? If YES please give details on the separate sheet provided Cover Requirements 16. Please specify the limit (s) of indemnity for which quotations are required: GBP GBP GBP GBP GBP Please specify the excess you would be prepared to carry GBP GBP GBP GBP GBP 5 of 7
Additional Information Please use this space to provide further information in support of answers given to questions in this proposal. Please state question numbers clearly. 6 of 7
Declaration I /We declare that the statements and particulars in this proposal are true and that no material facts have been misstated or supressed after enquiry. I / We agree that this proposal, together with any other information supplied shall form the basis of any contract of insurance effected thereon. I / We undertake to inform the insurers of any material alteration to those facts occurring before the completion of the contract of insurance. Signed: Title: Firm(s): Date: QPI Legal Unit 17 Mobbs Miller House Ardington Road Northampton NN1 5NE Tel: 01604 712222 Fax: 01604 711221 hayley.dawson@qpiprofessional.co.uk 7 of 7