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IES-NTUC Income Professional Indemnity Insurance Scheme for

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									                       IES-NTUC Income Professional Indemnity Insurance Scheme for Engineering Consultants (Part 1)
                               Insurance Application Form for Small & Medium Sized Firms/Corporations
                                                         For Insurance Year 2010

IMPORTANT NOTICES

THIS APPLICATION FORM IS DESIGNED FOR SMALL & MEDIUM SIZED FIRMS/CORPORATIONS. PLEASE DO NOT COMPLETE THIS FORM:
1. If you are a Sole-Proprietor/Partnership/Corporation, and
   a. the total gross fee income of the Insured Firm(s)/Corporation(s) exceeds S$3,000,000 in your last audited financials; or
   b. there are more than 10 Registered Professional Engineers or more than 50 Engineering Practitioners* in the Insured Firm(s)/Corporation(s); or
   c. you are a Multi-disciplinary Firm/Corporation
2. If you are an Individual, you are earning more than S$300,000 per annum in your last income declaration for your Professional Engineering Work
Who should sign this form
This Proposal Form must be signed by a Principal / Partner / Director (as applicable)
All questions must be answered
You must answer all questions. If any question does not appear to be applicable, please indicate “NA’. If space for any answer is insufficient, please attach separate sheets
identifying the questions by number.
“Claims Made” Policy
The Policy applied for is written on a “Claims Made” form.
This means that the Policy will only respond to a claim that is first made against you and notified to the insurers during the period of insurance. In this respect, notification is
also required of any allegation, fact, incident or circumstance (collectively referred to as “circumstances”), which may give rise to a claim, of which you know or ought to have
known during the period of insurance. Unless provided otherwise, the Policy will respond to a claim from such notified circumstances, even if it is made subsequent to its
expiry.
For the avoidance of doubt, the cover provided is subject to the retroactive date specified in the policy, and all other terms and conditions of the insurance. The cover will apply
to claims that arise from work done since that retroactive date.
The Policy excludes all claims, and circumstances, which may give rise to a claim, of which you knew or ought to have known prior to the policy inception.
Other Matters
The completion and signing of this Proposal Form does not bind you or the insurers to complete the insurance.


Please send the original signed application form to the following address:                   You may contact any of the following persons for information and
                                                                                             assistance:
Lockton Companies (Singapore) Pte Ltd
36 Robinson Road                                                                             Mr Chin Ah Faat         }        Tel No. 6326 9242
#16-01 City House                                                                            Ms Tracy Ho             }        Tel No. 6326 9221
Singapore 068877                                                                             Mr C. Nandakumar        }        Tel No. 6326 9252
                                                                                                                              Fax No. 6225 0682



                                                                                         1
                          IES-NTUC Income Professional Indemnity Insurance Scheme for Engineering Consultants (Part 1)
                                  Insurance Application Form for Small & Medium Sized Firms/Corporations
                                                            For Insurance Year 2010
IMPORTANT NOTICE:
THIS APPLICATION FORM IS DESIGNED FOR SMALL & MEDIUM SIZED FIRMS/CORPORATIONS. PLEASE DO NOT COMPLETE THIS FORM:
1. If you are a Sole-Proprietor/Partnership/Corporation, and
   a. the total gross fee income of the Insured Firm(s)/Corporation(s) exceeds S$3,000,000 in your last audited financials; or
   b. there are more than 10 Registered Professional Engineers or more than 50 Engineering Practitioners* in the Insured Firm(s)/Corporation(s); or
   c. you are a Multi-disciplinary Firm/Corporation
2. If you are an Individual, you are earning more than S$300,000 per annum in your last income declaration for your Professional Engineering Work

As required under Section 25(5) of the Insurance Act Chapter 142 or any subsequent amendment thereof, you are required to fully and faithfully
disclose in this Proposal Form all facts and matters which you know or ought to know, otherwise the Policy issued pursuant to this Proposal Form may
be void

Name of Practice(s)                                               : ______________________________________________________________________________________________

Principal Address                                                 : ______________________________________________________________________________________________

Address of any other offices (if applicable)                      : ______________________________________________________________________________________________

Telephone / Fax / Email                                           : __________________________________________________ Is the Practice(s) GST Registered?: YES                            NO
IES Member Name / Membership No.                                  : ______________________________________________________________________________________________

You are a (please tick the applicable boxes)                            Sole Proprietor                                              Unlimited/Limited Liability Partnership

                                                                        Unlimited/Limited Liability Corporation                      Individual (Freelance Consultant)

Claims and Insurance Details

1.   Is the Sole-proprietor, or any of the partners or directors (where applicable) or employees ever been subject to disciplinary proceedings for professional misconduct?      YES      NO

2.   Have any claims for negligence or breach of professional duty been made in the last three years against the Practice(s), or any of its predecessors in business, or any
     prior practice of any of their present or former principal, partners or directors, or have circumstances been notified to insurers that might give rise to a claim?         YES      NO

3.   Is the Sole-proprietor, or any of the partners or directors (where applicable), AFTER ENQUIRY, aware of any claim or circumstances that might give rise to a claim
     against the Practice or its predecessors in business, or any prior practice of any of their present or former principal, partners or directors?                             YES      NO

If you have answered “Yes” to any of the above three questions, please provide details by separate attachment.

                                                                                                                                                                Please proceed to the next pages(s)




                                                                                                    2
                        IES-NTUC Income Professional Indemnity Insurance Scheme for Engineering Consultants (Part 1)
                                Insurance Application Form for Small & Medium Sized Firms/Corporations
                                                          For Insurance Year 2010

Name of Practice(s)                                       : ______________________________________________________________________________________________

Details of your staff

1. Particulars of ALL Registered Professional Engineers (as currently placed in the Register of the Professional Engineers Board for the purposes of the
   Professional Engineers Act Cap 253 or as amended) who are Principal/Partners/Directors/Employees of the abovementioned Practice(s) at the date of this
   Application Form


                                                                                            Year first                                  Please state Specialisation (C&S/
         Names as in their Practising Certificates           PE Registration No.                                 Designation
                                                                                            registered                                  Mechanical/ Electrical)




2.   Are any of the Registered PEs above either (i) an Accredited Checker (Building Control Act), (ii) an Authorised Examiner (Workplace Safety & Health Act),
     (iii) a Registered Inspector (Fire Safety Act), or (iv) an Electrical Engineer (Electricity Act), or (v) a Geotechnical Specialist (PE Act)?        YES             NO

     If the answer to the above is “Yes”, please state their name and their respective registrations here: ___________________________________________________________

     __________________________________________________________________________________________________________________________________________


3.   Please state the number of Engineering Practitioners in your Practice(s) other than the above PEs: ___________________________________________________________

     *   We define Engineering Practitioners as either a PE or a partner/director/employee who holds the requisite educational qualifications for registration as a PE with the
         Professional Engineers Board of Singapore but is not currently registered as a PE. For the avoidance of doubt, engineering diploma holders, technicians,
         administrative staff need NOT be included here, please do not do so as it will affect the premiums quoted)

                                                                                                                           (Please use additional sheet(s) of paper, if necessary)


                                                                                        3
                       IES-NTUC Income Professional Indemnity Insurance Scheme for Engineering Consultants (Part 1)
                               Insurance Application Form for Small & Medium Sized Firms/Corporations
                                                         For Insurance Year 2010

Other Questions

1.   What is/are the Limit(s) of Indemnity you are requesting for under this Proposal?

        S$250,000 each and every claim and in the aggregate                                   S$500,000 each and every claim and in the aggregate

        S$1,000,000 each and every claim and in the aggregate                                 S$2,000,000 each and every claim and in the aggregate


2.   Deductible:

     Annual Fee Revenue                                           Deductible                                        Please tick
     Below S$500,000                                              S$5,000 eec
     S$500,000 to below S$1,000,000                               S$10,000 eec
     S$1,000,000 to below S$3,000,000                             S$20,000 eec

3.   What is the retroactive date you wish to apply to your Scheme policy?                                                                    ____________________________

4.   Would you require a letter from the Insurer to state that the policy complies with Section 24 of the Professional Engineers Act?                       YES    NO


                                                                                         Declaration

                                           I/We declare that the particulars given above are true and correct at the time of this application.


                                                                                              Date:
                        Signature:
                                                                                              Name/ Stamp of Practice:
                        Full Name:

                        Designation:


Important Disclaimer : The role of the Institution of Engineers Singapore (“IES”) in the IES-NTUC Income Professional Indemnity Scheme is non-commercial, and acts only as
a service to IES members by providing them with more options for their Professional Indemnity Insurance. Members should make their own assessment and decisions relating to
their insurance requirements. The IES shall not be responsible for deficiencies (if any) in the policies. The role of Lockton Companies (Singapore) Pte Ltd is solely as
Administrator in the management and claims handling of the Scheme.

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