PROFESSIONAL INDEMNITY PROPOSAL FORM

FULL NAME OF PROPOSER

ADDRESS

OCCUPATION/BUSINESS

TELEPHONE NO.

Format: (000) 000-0000.

FAX

EMAIL

example@example.com

Date

WHEN WAS THE COMPANY ESTABLISHED

Details of all principals or partners

i Qualifications

ii Date

Date

iii qualified/total duration of professional experience

iv How long in the same area?

v Position held in Company and how long

Total number of principals, partners and staff

Principals, Partners or officers
Sales persons
Staff other than typists and offices staff(please speficy)
Typists and office staff

Please provide a full description of the activities undertaken by the proposer

Is the proposer admitted to any Association or accredited to any quality systems?

If yes, please provide details

Does the proposer have written procedures or checklists for the service performed?

If yes, please provide details

Does the proposer subscribe to any form of Continuing Professional Development?

If yes please provide details

What are the proposers procedures in reviewing the work undertaken by staff and partners

Nature and volume of your present and foreseeable future activities

1 Describe your company by showing the percentage of gross profits to be received from all activities during the current fiscal year

2. Does the company's practice extend or has it ever extended to activities abroad? if so, please indicate:Type a question

In which countries and respective share of total business?

a Method of handling such business

Please indicate your fiscal yearType a question

a Last fiscal year?

b Current fiscal year? (Estimate)

C Next fiscal year? (Estimate)

Previous insurance/previous claims Have you previously been insured: Yes/No If so please specify:

Rows	Name of Insurer	Policy period	Limit of indemnity
1
2
3
4
5

Have any claims been made during the past 5 years against your company?

Is your company aware of any circumstances or incidents, which may result in a claim against your company?

Limit any one claim

Aggregate limit

Extended claims reporting period

Loss of documents

If so, up to what amount?

DECLARATION

It is the duty of the proposer to disclose all material facts relevant to the risk. A material fact is one that is likely to influence our judgment and acceptance of your proposal. If your proposal is a renewal, it should include any change in facts previously advised to us. If you are in any doubt about facts considered material, disclose them. Please note that failure to disclose a material fact or if any information provided proves to be incorrect, we may void your policy and decline to pay any claim.

I/We declare that the statements and particulars made by me/us in this proposal are, to the best of my/our belief, complete and true and I/we agree that this proposal, together with any other information supplied by me/us, shall form the basis of the contract of insurance effected thereon. I further declare and agree that if the statement and particulars above have been completed in the handwriting of any other person other than the undersigned, such person is deemed to be the representative of the proposer for the purpose of completing this proposal. Signing this proposal form does not bind the proposer or underwriter to complete this insurance.

Date

Signature

Agent

PROFESSIONAL INDEMNITY PROPOSAL FORM

What are the gross turnover for:

If so, please advise amount and background of each claim

Indemnity required

Endorsement to basic cover