Professional Indemnity Insurance Proposal for E nvironm ental Consultants PROFESSIONAL RISKS 2nd Floor John Stow House 18 Bevis Marks London EC3A 7JB Tel 020 7623 4957 Fax 020 7623 4958-1-
PROFESSIONAL RISKS Kerry London Ltd, Professional Risks, 2 nd Floor, John Stow House, 18 Bevis Marks, London EC3A 7JB Environmental Consultants Proposal Form Please answer all questions leaving no blank spaces. If you have insufficient space to complete any of your answers, please continue on your headed paper. This form must be signed and dated by a partner, principal, director or identified officer of the firm. If you have a brochure about your firm s operation(s), please forward it with this application. 1 Title of firm(s) 2 Address(es) of firm(s) if more than one, please give each address and indicate Partner, Principal or Director who is responsible for work at each address Tel No: E-mail: Fax No: 3 When was the firm established? 4 During the past five years has the name of the firm been changed or has any other business been purchased or any merger or consolidation taken place? If YES, please give full details -2-
5 Please give the following details Name of all Directors/Principals/Partners Qualifications Date Qualified How long as Partner/Director/ Principal of this Firm How long a Partner/Director/ Principal Note: Please supply a full Curriculum Vitae in respect of any Partner, Principal or Director who does not hold relevant Institute and/or academic qualifications 6 (a) Please give total numbers of personnel employed by the company (including those listed in question 5) by identifying each person by their primary function or skill set (please ensure that you only list each individual once). Number of chemists Number of chemical engineers Number of environmental scientists Number of geologists or hydro-geologists Number of occupational hygienists Number of toxicologists Number of general engineers Number of administrative staff Others (please specify) (b) How many of those listed in questions 5 or 6(a) have chartered status or equivalent? (c) Have any of those listed in questions number 5 or 6(a) ever been the subject of disciplinary action by any relevant authority as a result of any professional activities If YES, then please give details -3-
7 Please identify the range of professional services for which Professional Indemnity Insurance cover is being sought 8 Please indicate the gross income that the firms derived from the following areas of work: GROSS INCOME ( s) SCOPE OF SERVICES PREVIOUS YEAR CURRENT YEAR ESTIMATED NEXT YEAR (a) (b) Environmental studies, reports, assessments or audits Remedial investigation and feasibility studies where firm is not involved in design (c) Site selection evaluation: (i) Real estate selection (ii) Waste disposal site selection (iii) Other (..) (d) (i) Pre-acquisition audits (ii) De-investment audits (e) Preparation of environmental permit applications (f) Design without supervisory services: (i) General Design (ii) Environmental design (iii) Other ( ) (g) Design without supervisory services: (i) General Design (ii) Environmental design (iii) Other ( ) (h) General consulting (I) Project Management (i) General (ii) Environmental (iii) Other (..) TOTAL -4-
9 Please give fees received during the past five years Year United Kingdom EC USA/Canada Rest of World Estimated for coming 12 months TOTAL (b) In the case of Overseas Contracts, please list countries involved and whether UK or Overseas jurisdiction applied, also please supply brief details of these contracts and their size to be shown on your headed paper please 10 (a) What substantial changes in the amounts stated in questions 8 & 9 above does the firm foresee during the next 12 months? (b) Please give any details of any major new operations being undertaken during the next 12 months? (c) Please comment on any features of your work which you think may be of interest to Underwriters? 11 List the five largest jobs performed by your Firm and five typical jobs, giving brief details of income / fees received and a short description of contracts, performed during the last five years:- Date started Name & Type of Project Services Performed Total Contract Value Estimated date of completion 1 2 3 4 5 If you need additional space to complete this question please utilise a sheet of your letter headed paper. -5-
12 (a) Is this Firm or any Partner/Principal/Director connected or associated (financially or otherwise) with any other Practice, Company or Organisation? Yes/No If YES, please give full details 12 (b) Is this Firm or any Partner/Principal/Director or any associated Practice, Company or Organisation involved in any process of manufacture or construction? If YES, please give details 13 Is this Firm or any Partner/Principal/Director a member of a Consortium or Group Practice? If YES, please state in what capacity and the give names of other members and their capacities in the Consortium or Group Practice Name Capacity Details of Job 14 (a) Are all specialist designers/consultants appointed contractually required to maintain their own professional indemnity insurance? If YES to what minimum limit of indemnity are such specialist designers/consultants required to maintain their own professional indemnity insurance to? (b) (c) Do you have in place a formal system to ensure that specialist designer/consultants appointed maintain adequate professional indemnity insurance for the period of their liability? Is all specialist designers/consultants work checked by you? -6-
15 Does the Firm or any of its members have any involvement in any hazardous and/or non-hazardous waste treatment, processing, incineration or disposal facilities? If YES, please provide details: 16 Does the Firm or any of its members have any involvement in laboratories or facilities involved in the conducting of sampling and/or laboratory? If YES, please provide details: 17 Does the Firm have a standard contract that it utilises when entering into contracts with it s clients? If YES, please provide details below: (please also provide a copy of the contract terms separately) 18 Is the Firm BS 5750 (Quality Assurance) accredited or does it have any internal quality assurance systems? If YES, please provide details: 17 Insurance Provisions Note: If this is a renewal placed through Kerry London Ltd there is no need for you to answer this question (a) Please give particulars of previous similar Professional Indemnity Insurance during the past two (2) years Period Insurer Limits Excess -7-
17 (b) Has any Proposal for similar Insurance made on behalf of the Firm, any predecessors in business, or present Partners, Principal or Directors ever been declined or has any such Insurance ever been cancelled or renewal refused? If YES, please give details 18 Has any claim such as would be covered by the proposed insurance ever been made against this Firm or any of its Partners/Principals/Directors whilst in this or any other Firm? If YES, please provide details 19 Are any of the Partners/Principals/Directors or employees, AFTER FULL ENQUIRY, aware of any circumstances or incidents which may give rise to a claim against this Firm or their predecessors in business or any of the present or former Partners/Principals/Directors? If YES, please give full details (We must stress that it is imperative you answer this question correctly. FAILURE TO DO SO COULD WELL PREJUDICE YOUR RIGHTS if subsequently, a claim should arise) 20 Do you require Insurance for (a) Loss of Documents (b) Dishonesty of Employees (c) Libel & Slander (d) Unintentional infringement of copyright (e) Unintentional breach of confidentiality (f) Professional Office Package (includes Office Contents, Computer Equipment, Portable Equipment, Loss of Revenue, EL Wageroll, General Liability & Legal Expenses cover) (A separate submission will be required for this insurance) -8-
21 What is the amount of indemnity required? 100,000 250,000 500,000 1,000,000 2,000,000 5,000,000 or more 21 What is the amount of the excess, which your Firm would be prepared to carry in respect of each claim? 1,000 5,000 10,000 25,000 50,000 or more (Insurers require minimum excesses, depending on the size of the Firm and the type of work undertaken) DECLARATION please attach a brochure and Curriculum Vitae if applicable 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 my Contract of Insurance effected thereon. I/We undertake to inform Insurers of any material alteration to these facts occurring before completion of the Contract of Insurance. Signing this proposal form does not bind the Proposer or Insurers to complete this insurance. Name(s) of Firm(s) Signature of Senior Partner, Principal or Director Date E.U. Disclosure Clause (UK) Notice to the Proposed/Assured The parties are free to choose the law applicable to this Insurance Contract. Unless specifically agreed to the contrary, this insurance shall be subject to English Law. Any enquiry or complaint should be addressed in the first instance to your Broker. Kerry London Ltd 2nd Floor John Stow House 18 Bevis Marks London EC3A 7JB Tel: 020 7623 4957 Fax: 020 7623 4958 Registered in England No. 2006558 Authorised and regulated by the Financial Conduct Authority -9-
PROFESSIONAL RISKS Kerry London Ltd, Professional Risks, 2 nd Floor, John Stow House, 18 Bevis Marks, London EC3A 7JB USEFUL CHECKLIST FOR THE ENVIRONMENTAL CONSULTANTS PROPOSAL FORM When completing the proposal form please just take a minute to check the following points have been taken into consideration. This will assist us in providing you with an expedient and competitive quotation. (Question 1) Ensure that all of the companies trading titles that require coverage are clearly shown under question 1. This should also include but not be limited to past trading titles and/or companies. (Question 5) If any Director, Principle or Partner of the company does not have a recognised industry qualification; please ensure that that individual s CV is also attached to this application. (Question 8) This question asks for an activity breakdown for the company. You must therefore ensure that you take particular care when answering this question, as Insurers will utilise this question to calculate your premium. (Question 18 & 19) Please ensure that all claims information is provided for both present and past claims matters. This means any claim and/or circumstance that may lead to a claim should be clearly shown within the proposal form or on separate sheet of your letter headed paper. The proposal form must be signed and dated by a company director, partner or principle in order to legally validate the information provided. Please note: This application form has been designed for businesses that have been trading for more than 12 months. If your practice has not been trading for 12 months please try to answer all of the questions that will reflect your companies proposed activities for the next 12 months. If you are ever unsure what information is required from you when completing this form please ensure that you contact your broker immediately. -10-