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 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 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: 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: GBP Largest Fee: GBP Page 3

4 Section 3 Income Split For your last complete Financial Year, please provide the percentage split in your income between all categories of work: Please specify your categories of work below: % TOTAL Section 4 Overseas Operations Please list the countries involved in your overseas operations. Section 5 USA and Canada If you undertake any work which is either domiciled in the USA or Canada or under their laws and jurisdiction please provide full details below. Page 4

5 Section 6 Anticipated Changes Do you anticipate any major changes in your business activities in the forthcoming 12 months? Section 7 Additional Cover Have you undertaken any activities other than those shown for the last complete year as per Section 3, for which cover is required? Section 8 Valuations Have you undertaken any valuations for lending purposes? Section 9 Involvement in other sectors Are you involved in any process of manufacture, construction, alteration, repair, installation, sale or supply of products? Page 5

6 Section 10 Employment of Sub Consultants Do you appoint independent or specialist sub consultants? If YES, please state: 1) What percentage of gross income/fees was paid to specialists, designers or consultants in the last year? 2) Are specialists, designers or consultants required to carry professional indemnity insurance? If YES, to what limits? 3) Do you get an indemnity from sub-contractors in writing? If YES, to what limits? Page 6

7 Section 11 Contracts Undertaken Please give details of the five largest contracts undertaken in the past six years: Client Start Date dd/mm/yy Extent of Services Total Contract Value Your Fee Completion Date dd/mm/yy Please give details of the five new projects likely to commence in the coming 12 months: Client 1 Start Date dd/mm/yy Extent of Services Total Contract Value Your Fee Completio n Date dd/mm/yy Page 7

8 Section 12 Claims 1) After enquiry, have any Professional Indemnity claims been made against the firm(s) and/or predecessors of the firm(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 provide full 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 or principles aware of any pending claims and/or circumstances which are likely to 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)? Date of claim/loss Brief details of each claim/loss Amount of Claim paid Reserve/ Outstanding Page 8

9 Section 13 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 9