WHEN COMPLETING THIS PROPOSAL FORM:

Transcription

1 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 for the purpose of requesting Directors and Officers Liability insurance for the firm who acts as a Proposer. THIS PROPOSAL FORM DOES NOT BIND THE PROPOSER TO COMPLETE THE INSURANCE BUT WILL FORM PART OF ANY CERTIFICATE OF INSURANCE THAT IS SUBSEQUENTLY TAKEN OUT WITH US. DUAL Corporate Risks Limited is authorised and regulated by the Financial Conduct Authority. 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 Page 1

2 Section 1 Details of the Proposer Name of the firm Date of commencement of firm Business description Personnel head count Directors: Qualified Staff: Sub Consultants: Others: Page 2

3 Section 2 Fee Income Fee income for the last three complete financial years: UK For each of the last three financial years: Date / Month / Year 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: Date / Month / Year 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: Date / Month / Year 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 Page 3

4 Section 3 Fee Splits Please provide the split of gross fees received in the last complete financial year: Architectural Consulting Civil Engineering Structural Engineering Mechanical Engineering Electrical Engineering Soil and Foundation Engineering Structural Surveyor Inspection Reports Laboratory Analysis Cladding / Roofing / Flooring Town Planning Quantity Surveying Project Management Project Co-ordination Environmental Feasibility Studies Structural Surveys Heating and Ventilation Aborted Work Other (please detail below): TOTAL 100 Page 4

5 Section 4 Project Types 1) Please indicate the approximate percentage of the total fees the company derives from work where the main contract or interest is: Approximate percentage (in none, state None ) a) Feasibility studies, reports, surveys, etc. (where the company is not involved in actual design work) b) Bridges and/or Tunnels c) Dams and/or Mines d) Harbours and/or Jetties and/or Offshore Installations e) Sewerage and/or Water Schemes f) Foundations and/or Underpinning g) Soil Testing h) Nuclear or Atomic Projects i) Chemical, Petro-Chemicals and Refineries j) Industrial Systems Buildings k) Heating, Ventilation and Air Conditioning l) Housing m) High Rise Buildings n) Schools, Hospitals, Municipal Buildings o) Mechanical Plant and Bulk Handling Equipment (including silos, etc.) p) Other work including any specialist activities not shown above (please specify) TOTAL 100 2) Supervision of Construction a) Proportion of work where company both designs and supervises the actual construction b) Proportion of work where company provides technical supervision of construction from the designs of other companies TOTAL 100 Page 5

6 Section 5 Anticipated Changes Do you anticipate any major changes in your business activities in the forthcoming 12 months? If YES, please provide full details below (use separate sheet if necessary): Section 6 Sub-Contractors 1) Do you appoint independent or specialist sub-contractors/consultants? If YES, please state: What percentage of gross income/fees was paid to subcontractors in the last financial year? Are financial checks carried out on specialists, designers or consultants who are appointed by you, prior to their appointment? Are sub-contractors required to carry professional indemnity insurance? If YES, to what limits? Do you always get an indemnity from sub-contractors, for their negligence in writing? If YES, to what limits? 2) Please describe the work and activities of the specialists, designers or consultants (use separate sheet if necessary): 3) Are they always professionally qualified or have at least five years experience? Page 6

7 Section 7 Contracts Undertaken 1) a) Please give details of the five largest contracts undertaken in the past 6 years Client Start Date dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy Description Extent of Services Total Contract Value Fee GBP GBP GBP GBP GBP Approx. Completion Date dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy Page 7

8 b) Please give details of the five new projects where construction is likely to commence in the coming 12 months Client Start Date dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy Description Extent of Services Total Contract Value Fee GBP GBP GBP GBP GBP Approx. Completion Date dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy dd/mm/yyyy 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 4) Have you ever failed to complete a project? If YES, please explain the reason and provide details about the project (use separate sheet if necessary): Page 8

9 Section 8 Claims 1) After enquiry, have any Professional Indemnity claims been made against the firm (s) and/or predecessors of the practice(s) and/or your current and/or retired partner(s), director(s), or principal(s), either individually or otherwise, whether successful or not within the past ten years? If YES, please give details: Date of claim/loss Brief details of each claim/loss Amount of claim paid Reserve/ Outstanding 2) After enquiry, are any of the partners, directors, members or principals aware of any pending and/or circumstances which likely give rise to a claim against the firm(s) and/or predecessors of the firm(s) and/or your current and/or retired partner(s), director(s), member(s) or principal (s)? If YES, please give details: Date of claim/loss Brief details of each claim/loss Amount of claim paid Reserve/ Outstanding Page 9

10 Section 9 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 ENG Page 10