Engineers Professional Indemnity Insurance

Transcription

1 Engineers Professional Indemnity Insurance Instructions Please provide a full answer to every question. A Partner/Director/Principal must sign and date this form and any separate sheets on behalf of the firm having consulted to ensure that the answers given are true and complete. Please include with this form a sheet of your current HEADED NOTEPAPER, which can also be used to supplement areas where you may have sufficient space to answer a question. Proposer Details Please note: If there are additional Insured s that cover is required for under this policy, you should answer all questions on this proposal form in relation to all parties to be insured under this policy. 1. Companyname: 2 Address (including associated or subsidiary companies) requiring cover under this policy: 3. Web-site address: address: Telephone : Fax :

2 4. Date business established: 5. Please provide a description of your business activities: 6. Have the activities altered substantially since establishment and/or are any changes anticipated in the next 12 months? If, please provide full details: 7. Are you connected or associated (financially or otherwise) to any other business? If, please provide full details: 8. Are you a member of any Professional Association? If, please provide full details: 9. a) Please provide name(s) in full of partners/directors of firm/company and any employee carrying out professional work: Name Qualifications Date Qualified Number of Year s Experience

3 b) Please confirm that one or more Principals have at least five years experience in the relevant industry: If NO, please provide CV s for all Principals 10. Number of employees, including principals/partners/directors: Qualified n Qualified a) Give details of your fees/income derived from clients based in: UK USA/Canada Elsewhere Actual For Last Financial Yeard Estimate for Current Financial Year Estimate for Next Financial Year If any work is undertaken outside of the UK please give details of location, type of work and Income derived: b) On what date does your financial year end? 12. Please provide an approximate percentage split of the disciplines in which you are involved: Electrical engineering % Heating & ventilation and air conditioning engineering % Mechanical engineering % Civil engineering % Structural engineering % Process engineering % Architectural % Nuclear engineering % Planning supervision % Other please provide full details % 100%

4 13. Have you undertaken contracts involving any of the following in the last five years? Manufacturing plant Power Plant Sewerage & water schemes Petrochemical & refineries Roads, bridges, tunnels & dams Harbours & Jetties Mines & associated works Housing/commercial schemes above three floors Swimming pools Foundations/underpinning te: If you have answered YES to any of the above, please provide full details on a separate sheet. 14. Do you undertake any contract which involves: a) Manufacture, construction, erection or installations? b) Supply of any goods, materials, plant or equipment? If, please provide details: 15. During the last complete financial year what percentage of your work involved: Project management % Project co-ordination % Supervision of construction % Feasibility studies % Aborted projects % *Please note the above percentages are not expected to total 100%

5 16 Please give details of the three largest contracts you have carried out in the past five years (in terms of total project value) where you had responsibility for design or other professional services: Year Client Your contract value Total contract value Description of your activities Fees earned 17. Do you use sub contractors? If : a) What percentage of fees are paid out to them: % b) Please provide details of the work they carry out: c) Do you ensure that they have their own Professional Indemnity Insurance in force? 18. Do you currently have a professional indemnity insurance policy in force? If, please advise the Insurer. Premium.. Renewal Date.. Retroactive Date 19. Please indicate the level(s) of indemnity you would like us to obtain quotations for: 250, ,000 1,000,000 Other 20. A self-insured excess will apply to any claim. The Underwriter will decide what the minimum amount will be when assessing your risk however, if you prefer to carry a higher level of excess, which may reduce the premium, please indicate as below:

6 21. Do you currently have an individual(s) responsible for risk management strategy with your business? If, please provide full details: 22. Have you ever had any insurance or proposal cancelled, withdrawn, declined or made subject to special terms? If, please provide full details: 23. Have you sustained any loss through the fraud or dishonesty of any person or are you aware of any fraud or dishonesty at any time of any past or present partner, director or employee? If, please provide full details: 24. Has any claim, or are you aware of any circumstance that may give rise to a claim, whether successful or not been made against you or your predecessors in business or any past or present principal, partner, director or employee (whether insured or not)? If, please provide details:

7 SIGNING THIS PROPOSAL DOES NOT BIND THE PROPOSER TO COMPLETE THIS INSURANCE Declaration I/We declare that the statements and particulars in this proposal are true and that no material facts have been mis-stated or suppressed after enquiry. I agree that this proposal, together with any other information supplied shall form the basis of any contract of insurance effected thereon. I undertake to inform the Insurers of any material alteration to those facts occurring before the completion of the contract of insurance. Signed.. Title. (to be signed by Partner, Director or Principal or equivalent) Firm(s) Date. Contact Details for the Professional Indemnity Team Please return the completed proposal form to: Professional Construction Risks Ltd PCR House Unit 2 Ebdon Bow Wick St Lawrence Weston-Super-Mare Somerset BS22 9NZ Telephone: info@professionalconstructionrisks.co.uk Web: Professional Construction Risks Ltd is authorised and regulated by the Financial Conduct Authority. Our firm reference number is

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