Professional Indemnity Insurance (Miscellaneous Classes)

Transcription

1 Proposal Form Professional Indemnity Insurance (Miscellaneous Classes) ADNIC is a Public Joint Stock Company incorporated in the United Arab Emirates by Law. (4) of 1972, and it is governed by the provisions of the UAE Federal Law. (6) of 2007 Establishment of the Insurance Authority & Organization of its Operations, with Registration. (1). Completing this form In order to apply for this insurance, please complete all parts of this proposal form and the annexures, if any. You must provide full, accurate, and true answers to all questions listed below. Material facts which you know or ought to know should be fully and accurately disclosed. Failure to do so may result in rejecting your claim and/or terminating the insurance policy from inception. If you are in any doubt about what you should disclose, please do not hesitate to contact us. A material fact is one that would influence our decision whether to offer you insurance or the terms which we offer. If the space provided is inadequate, please provide details using an additional information sheet, signed and dated. Your insurance does not commence when you sign the proposal. Your cover will only commence once we have reviewed the proposal form and confirmed cover in writing. Please keep a copy of this proposal form for your record along with any correspondence/ information provided to us and policies/endorsements that are issued to you subsequently. 1/7

2 1. General information a. Name of firm and date when first established, including subsidiary, associated, or predecessor firms for which cover is required b. Address (Please show the address required on the policy) Contact person s name: P.O. Box: Country: Phone number: Fax number: City: Mobile number: address: Website address: Address of branches c. VAT Tax Registration Number (if applicable): 2. Directors/Partners and staff information a. Names of all Directors/Partners Qualifications (Please provide curriculum vitae if no relevant institute/ academic qualifications) Year obtained How long has the Director/ Partner been in the firm If less than 5 years practical experience in this occupation, please give details of previous occupation b. i) Total number of staff, other than typists/clerical workers ii) Typists and clerical workers 2/7

3 2. Directors/Partners and staff information (continued) c. If sole director/partner, please answer the following: Is this a part-time occupation? If, please give brief details of present full time occupation: 3. Firm details a. Description of firm s activities for which cover is required (If there is more than one activity, please detail percentage split for each category) b. Are any major changes in the firm s activities planned or expected within the next two years? If, please give details: c. Is the firm or any of the directors/partners connected or associated (financially or otherwise) with any other firm, company or organization? If, please give details: Director/Partner Nature and name of association d. Does the firm perform work outside the UAE or work for clients outside the UAE? If, please give details, including countries and proportion of fees from this work 3/7

4 3. Firm details (continued) e. Does the firm use a standard form of contract, agreement, or letter of appointment? If, please enclose copies. f. Does the firm issue any brochure, leaflets, books, etc. describing the firm s services or offering any service or facility? If, please enclose copies. 4. Gross income/fees Please give the amount of gross income/fees from the following: a. Last financial year: b. Previous financial year: c. Current financial year (estimate): d. Date of financial year end: e. Largest annual fee from any one client: 5. Sub-contractors details Is any work put out to sub-contractors? If, please give details, including: a. Does the firm require sub-contractors to carry insurance and for what limit? b. What percentage of the firm s fees is paid to sub-contractors? c. Nature of sub-contracted work: 4/7

5 6. Previous applications for insurance Has any proposal for similar insurance made on behalf of the firm, any predecessors in business or present partners or directors, ever been declined or has such insurance been canceled or renewal refused or special terms imposed? If, please supply details: 7. Present insurance Please give particulars of the firm s present insurance Amount of indemnity Excess Premium Insurer Renewal date How long continuously insured 8. Claims a. Have any claims been made against the firm or its present or past directors/partners (whether insured or not?) If, please give details of paid claims including quantum and background of each claims b. Are any of the directors/partners, after inquiry, aware of any circumstances which may give rise to a claim against the firm or its predecessors in business or any of its present or former directors/partners? If, please give details: 5/7

6 8. Claims (continued) c. What is the limit of indemnity is required? (please tick) AED 250, ,000 1,000,000 d. What is the amount of the deductible which your firm would be prepared to carry in respect of each claim? (please tick) AED 2,500 AED 5,000 AED 10,000 AED 25,000 AED 50,000 AED 100,000 AED (Underwriters require minimum deductible, depending on the size, type of work undertaken) 9. Insurance requirement Do you require insurance for: a. Loss of documents (Delete where applicable) If, then indicate what limit AED 5,000 AED 10,000 AED b. Dishonesty of employees (Delete where applicable) c. Libel or Slander (Delete where applicable) 6/7

7 Declaration I/We hereby declare that the statements/information given by me/us in the Proposal Form are full, accurate and true. It is hereby understood and agreed that the statements, answers and particulars provided in this Proposal Form and as per the attachments are the basis on which the insurance policy is being issued/effected. If after the insurance policy is effected, it is found that any fact in the statements, answers or particulars in this Proposal Form is incorrect, untrue, inaccurate, misrepresented or non-disclosed in any material respect, ADNIC shall have no liability under the insurance policy and/or shall have the right to terminate the insurance policy from inception. Name of Proposer: Title: Signature: Stamp: Date: te: Please note that each page of the proposal form should be signed by the Proposer or its legal representative 7/7