SIGNING THIS PROPOSAL FORM DOES NOT BIND THE PROPOSER OR THE INSURER TO COMPLETE THIS INSURANCE

Transcription

1 Your DUAL Professional Insurance Certificate is issued on a CLAIMS MADE basis. WHEN COMPLETING THIS PROPOSAL FORM: Please answer all questions giving full and complete answers. It is the duty of the Proposer to provide all information that is requested in the Proposal Form and any additional material facts. A material fact is such known fact and/or circumstance that may influence the evaluation of the risk by the Insurer, and may influence the acceptance of this application for insurance. If you have any doubts about what a material fact is, please do not hesitate to contact your Broker. If you fail to disclose a material fact, it may affect how Claims are settled under the policy or it may render the policy invalid. If the space provided on the Proposal Form is insufficient, please use a separate signed and dated sheet in order to provide a complete answer to any question. The Proposal Form must be completed, signed and dated by a person, who must be of legal capacity and authorised. SIGNING THIS PROPOSAL FORM DOES NOT BIND THE PROPOSER OR THE INSURER TO COMPLETE THIS INSURANCE DUAL Corporate Risks Limited is authorised and regulated by the Financial Conduct Authority under Financial Services Registration number Registered address: 107 Leadenhall Street, London EC3A 4AF, United Kingdom. Part of the DUAL Group. Registered in England and Wales under company registration no T: +44 (0) E: reception@dualgroup.com

2 Section 1 Details of the Proposer 1) Name of the Firm Date of Commencement of Firm Please state the business activities of the firm Principal Address of the Firm Post code: Principal in Charge Website Address Number of other offices Details of other offices Page 2

3 2) List of all the Principals, Partners or Directors Name in full of Principals, Partners, Directors Qualifications Date Qualified How long with the Proposer? Full time or Part time 3) Is cover required for previous business activities of any Principals, Partners or Directors? If YES, please provide full details below (continue on separate sheet if necessary). N.B. THE PREVIOUS BUSINESS ACTIVITIES MUST BE THE SAME AS THE CURRENT BUSINESS ACTIVITIES OF THE PROPOSER IF COVER IS TO BE PROVIDED 4) Please State Total Numbers of: Qualified Staff Sub Consultants/ Sub Contractors Others 5) Please State the Name of any Professional Body or Trade Association of which the firm is a member Professional Body Trade Association Page 3

4 Section 2 Fee Income Please state fee income for the last three complete financial years: 1) TOTAL GBP GBP GBP UK For each of the last three financial years: dd / mm / yy Average Fee Largest Single Fee Total Gross Fee Y1:Date / Month / Year GBP GBP GBP Y2:Date / Month / Year GBP GBP GBP Y3:Date / Month / Year GBP GBP GBP Estimated gross fees for the current financial year GBP GBP GBP USA/Canada For each of the last three financial years: dd / mm / yy Average Fee Largest Single Fee Total Gross Fee Y1:Date / Month / Year GBP GBP GBP Y2:Date / Month / Year GBP GBP GBP Y3:Date / Month / Year GBP GBP GBP Estimated gross fees for the current financial year GBP GBP GBP Rest of World For each of the last three financial years: dd / mm / yy Average Fee Largest Single Fee Total Gross Fee Y1:Date / Month / Year GBP GBP GBP Y2:Date / Month / Year GBP GBP GBP Y3:Date / Month / Year GBP GBP GBP Estimated gross fees for the current financial year GBP GBP GBP 2) Average Fee Largest Fee Estimated fees for financial year ending: / / GBP GBP GBP Page 4

5 Section 3 Categories of Work Please categorise the activities outlined above and indicate the approximate percentage of gross income/fees each represents: Package Software (sale of third party software) % Package Software (own products) design & sale Customisable Software design & sale Bespoke Software design System Analysis Data Processing Facilities Management Sale/Supply Hardware Website Design & Build Trading Website Design & Build Non Trading Supply of Contract Staff Domain Name Registration Web Hosting Software Maintenance Software Installation / no design General PC Advice Strategic Planning Procurement Consultancy Training Trouble Shooting Project Management System Audit ISP (Internet Service Provider) ASP (Application Service Provider) Hardware Maintenance/Installation Other (please detail below)..... TOTAL Page 5

6 Section 4 Troubleshooting 1) Where do you think your business is exposed to potential claims? 2) In what circumstances might you envisage a claim arising? 3) Do you anticipate any major changes in your business activities in the forthcoming 12 months? If YES, please provide full details below. 4) Is the failure of any of your products or services liable to result in any of the following outcomes, or do you work on any systems which could cause: Loss of life or injury to a person? Destruction or damage to physical property? Significant financial loss? If YES to any of the above, please provide full details below. Page 6

7 Section 5 Other Lines of Business 1) Are you responsible for, or do you provide advice in relation to, any of the following? Full project implementation of IT or other systems? Live trading or mission critical systems? Internet Service Provider (ISP services), Application Service Provider (ASP services) or financial transaction web site design? Fully outsourced or managed services? Security of systems or networks? If YES to any of the above areas please provide full details of your services and describe in detail the three largest contracts in which you have been involved on a separate sheet. 2) Have you undertaken any other activities in the past other than those shown for the last completed year as per Section 3 for which cover is required? If YES, please provide full details below. Section 6 Sub Contractors 1) Is any work assigned to sub-contractors? If YES, please state: 2) What percentage of gross income/fees was paid to specialists, designers or consultants in the last year? % 3) Are specialists, designers or consultants required to carry professional indemnity insurance? If YES, to what limits? Page 7

8 4) Do you get an indemnity from sub-contractors in writing? If YES, to what limits? 5) Do you require any sub-contractors to be indemnified under your insurance arrangements? If YES, please state: Name Qualifications Fees Paid (last financial year) Section 7 Contracts Undertaken 1) Please give details of the 3 largest contracts in the past 5 financial years (give details of current projects if new business) Client 1 Start Date dd/mm/yy Extent of Services Total Contract Value Your Fee Completion Date dd/mm/yy / / GBP GBP / / 2 / / GBP GBP / / 3 / / GBP GBP / / 2) What is the total income received in the last financial year from your largest client? GBP 3) What is the average fee received in the last financial year? GBP Page 8

9 4) Have you at any time accepted liability other than under jurisdiction of UK courts? If YES, please provide full details, listing jurisdiction and amount of work involved. 5) Do you use a standard form of contract, agreement or letter of appointment? If YES, please attach a copy with this Proposal form. 6) Do you only carry out work under contracts drafter by legal professionals and signed by clients? If NO, please explain on what basis you enter into contracts. Section 8 Joint Venture Partnerships Are you or have you been engaged in a Joint Venture Partnership? If YES, please give full details (including names of contracts). Section 9 Other Business Interests Does the proposer/s or any Principal have any association with or financial interest in any other Practice, Company or Organisation? If YES, please give full details (including names of contracts). Page 9

10 Section 10 Current Insurance Arrangements 1) Please give full details of any current insurance arrangements below. Period Insurer Limit Excess Premium GBP GBP GBP GBP GBP GBP GBP GBP GBP 2) For what limit/s of indemnity are quotations required? GBP 3) Do you require reinstatement of the limit of indemnity should a claim arise which erodes the original limit of indemnity (you may only reinstate the limit of indemnity once) Section 11 Claims 1) In respect of ANY of the risks to which this proposal relates, have any Claims been made (whether successful or not) against the proposer or any past or present Principal? 2) Has any loss been suffered by the proposer or any past or present Principal in respect of ANY of the risks to which this proposal relates? If YES, please give details: Date of claim/loss Brief details of each claim/loss Cost of Claim/Loss Estimated cost of claim/loss / / GBP GBP / / GBP GBP / / GBP GBP / / GBP GBP / / GBP GBP Page 10

11 3) What steps have been taken to prevent recurrence? 4) Is any Principal, AFTER FULL ENQUIRY, aware of any circumstance which might: Give rise to a claim against the proposer or any past or present principal? Cause any loss to the proposer or any past or present principal? Cause any proposal for similar insurance made on behalf of the proposer or any past or present principal to be refused or terms amended? Otherwise affect the consideration of this proposal for insurance? If YES, to any of the above, please give details: Page 11

12 Section 12 Declaration SIGNING THIS PROPOSAL FORM DOES NOT BIND THE PROPOSER OR THE INSURER TO COMPLETE THIS INSURANCE (a) We declare that the statement and particulars in this Proposal Form are true and that no material facts have been misstated or suppressed after enquiry. (b) We agree that should any of the information given by us alter between the date of this Proposal and the inception date of the insurance to which this Proposal relates, we will give immediate notice thereof. (c) We agree that any information provided in support of this application can be passed to our risk assessors. (d) We agree that this Proposal, together with any other information supplied by us shall form the basis of any contract of insurance effected thereon. TO BE SIGNED BY A PERSON AUTHORISED BY THE BOARD ONLY SIGNATURE DATE NAME POSITION DUAL Corporate Risks Ltd recommends that you keep a record of all information supplied for the purpose of entering into an insurance contract (including copies of this Proposal Form and correspondence) DUAL London Office Bankside House Leadenhall Street London, EC3A 4AF United Kingdom T: +44 (0) E: reception@dualgroup.com DUAL Manchester Office 6th Floor, Chancery Place 50 Brown Street, Manchester, M2 2JG United Kingdom Tel: +44 (0) E: reception@dualgroup.com SPE Page 12