QPI Professional Specialists in Protecting Professions Professional Indemnity Insurance Proposal Form for Accountants 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 14
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 If more than one office exists, please confirm if there is a senior Partner/Director/Member based at each office? If NO, please provide a C.V. of the person overseeing the office. 3. Type of practice and activities undertaken: 4. Professional Associations please indicate which association/s the proposer is a member of: ICAEW ACCA AAT CIMA ICAS CIPFA Other If other please provide details below: 2 of 14
5a. Please provide details below of any subsidiary companies which are to be included under this insurance (whether trading or ceased trading) Subsidiary Year Established Year of Cessation 5b. Is cover required for all past activities of the business included in 5a? 6. Is/are the firm(s) or any principal, partner or director a member of a joint venture, consortium, single project partnership or group practice? If YES please supply details: 7. Does the firm(s) or any principal, partner or director carry out any work on behalf of any other business in which they have a controlling or financial interest (other than as a shareholder in a public quoted company)? If YES please supply details below: 3 of 14
Staff and Partners 8. Please give details of all Partners, Directors or Members of the Firm (s): Full Name Age Qualifications Date Qualified State how long as Partner/Director/ Member Please use separate sheet for additional Partners, Directors or Members of the Firm (s). 9. Please give details of any consultants to whom work is sub-contracted that require cover Consultants Name Qualifications Fees paid last financial year Does the sub-contractor hold their own PI Insurance? 10. Please advise number of permanent staff (excluding Partners, Directors or Members) Qualified Full Time Qualified Part Time Other Full Time Other Part Time Activities of the Firm 11. Please provide the total gross fee income for the last 5 years Year Ending UK USA/Canada Elsewhere Total / /20 / /20 / /20 / /20 Last completed year Estimate next year 12. 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 4 of 14
13. 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 14. Please give the approximate percentage breakdown of your last Financial Year income / fees in the following categories: 1 Audit, Accountancy & Compliance Tax % (i) Quoted Companies % (ii) Unquoted Companies % (iii) Others (including Farmers, Small traders etc.) % 2 Other Taxation % 3 Payroll Services % 4 Management Consultancy % 5 Consultancy Only % 6 Secretarial and Share Registration % 7 Executorship and Trusteeship % 8 Insolvencies, Liquidations and Receiverships % 9 Insurance, Building Society & Stock Exchange Commissions % 10 Directorships % 11 Computer Consultancy % 12 Corporate Finance, Mergers, Acquisitions % 13 Investment Advice and other Financial Services work % 14 Other Work % Total (please check 1-8 equals 100%) 100% 15. For any activities where you have answered Nil, please give details if you have been engaged in such work in the last 6 years 5 of 14
16. If any fees are received in connection with; other work, management consultancy or computer consultancy give brief details of the work undertaken in the box below 17. Are there any changes in the above percentages or any major operations envisaged during the forthcoming year? If YES please give details 18. Is the firm authorised to conduct investment business and/or Financial Services? If YES please give details of your regulatory body 19. 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 document. 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? 6 of 14
20. Please give split of fees for the last financial year between: Fee Amounts No of Clients Total Fees Less than 15,000 15,000 to 40,000 Over 40,000 Totals 21. Please give details of type of business activities for your largest client 22. Does the firm undertake or has the firm previously undertaken work of any description for the following; i) Banks and other Financial Institutions ii) iii) iv) Insurance Companies, Lloyds Syndicates, Lloyd s managing or members agents or Underwriting Agencies Any off-shore companies Entertainment industry clients or sporting professionals If YES, please give details below of the name(s) of clients, fees earned and the services provided in the box below 7 of 14
Risk Management 23a. Does the Firm(s) always request satisfactory written references when engaging senior employees? 23b. Is any Partner, Director, Member or Employee allowed to sign cheques on his signature alone? 23c. If YES, please describe circumstances and state limit: 23d. Do all cheques for more than 25,000 require two signatures? 23e. Are employees receiving cash/cheques in the course of their everyday duties required to pay in daily? 23f. How often are checks carried out on all entries in the cash book with paying in books, receipts, counterfoils and vouchers and reconciled with bank statements, including the balance of cash and unrepresented cheques, independently of employees receiving or banking monies in respect of monies belonging to the Firm as well as in trust on behalf of others? Weekly Monthly Quarterly Other 24a. What is the management structure of the Firm(s)? Managing Partner Managing Executive Management Committee Executive Committee Other (please specify): 24b. Have there been any material changes in the management structure within the last three years? 24c. If the Firm(s) is managed by a committee, does this committee meet on a regular or ad hoc basis? regular ad hoc 24d. Does the Firm employ a full time non-accountancy administrator? 8 of 14
24e. Does the Firm(s) designate or employ an individual with management responsibility for evaluating or dealing with complaints, actual or potential claims and other such matters? 25. Does the Firm(s) have written risk management procedures which are regularly reviewed and circulated to all staff? If NO please provide full details 26a. Does the firm always use engagement letters? If YES, do the engagement letter outline: i) The scope of services to be performed? ii) Any statement / assumptions upon which the engagement is based? iii) The responsibilities of the client? iv) any limitations / restrictions in respect of any services performed? 26b. Does the client always sign the letter of engagement? 26c. Does the Firm(s) provide advice or services which fall outside the scope of the letter of engagement? 27a. Does the Firm(s) have a written policy specifying the conflicts of interest procedures which include a cross check system and back up? 27b. In the event of a conflict of interest does the Firm(s): Inform the client in writing? Advise the firm to seek independent advice? Continue to act for the client? 27c. Does the Firm(s) undertake any professional services for any client in which any Partner or Accountant holds a partnership / directorship or have any other financial interest? If YES, please provide details: 9 of 14
28. Does the Firm(s) have a policy which requires prior approval in writing for an Accountant to serve as an Officer and/or a Director of a client or third party applicable? 29. Does the Firm(s) operate a diary system with a manual back-up? If YES, (a) Are periodic checks made to ensure that the diary system is being strictly followed? (b) Does the diary system provide for accountants being absent or deadlines not being missed? 30. (a) Does the Firm(s) have a file review system which requires randomly selected files to be audited by an accountant other than the accountant handling the file? (b) Does the file review system include Partner to Partner auditing? Please provide any additional information that will assist our understanding of the file review system currently being used: 31. Does the Firm(s) offer and promote continuous training? If YES, please describe the continuous training provided? 10 of 14
Claims Information 32. After enquiry, have any professional indemnity claims ever been made against the Firm(s) and/or predecessors of the Firm(s) and/or your current and/or retired Partners, Directors or Principal, either individually or otherwise for any negligence, errors, omission, breach of professional duty or the like, whether successful or not? If YES, please supply details: Date of Claim (dd/mm/yy) Claimant Details of Claim, including amounts paid by insurer in respect of damages and legal costs 33. After enquiry, are any of the Partners, Directors or Prinicples aware of any pending claims and/or circumstances existing that may give rise to a professional indemnity claim against the Firm(s) and/or predecessors of the Firm(s) and/or your current and/or retired Partners/Directors/Principals? If YES, please supply details: Date of Circumstance Claimant Details 11 of 14
34. Is any Partner, Director or Principal, after enquiry aware of any disciplinary actions taken towards the firm and / or Partner / Director / Principal? 35. 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 a separate sheet Previous Coverage 36. Has the firm previously been insured for professional indemnity insurance? (If you are a current client of QPI Professional do not complete) If YES, please supply details: Renewal Date Limit of Indemnity Premium Excess Insurer Name 36a. 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 provide details: Cover Requirements 37. Please specify the limit(s) if 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 12 of 14
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. 13 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 14 of 14