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Professional Indemnity Insurance – proposal form




Crest Underwriting Limited is a Provisionally Accredited Lloyd's Broker.




Crest Underwriting Ltd is a Provisionally Accredited Lloyd’s Broker
Crest Underwriting Limited is regulated by the Irish Financial Services Regulatory Authority as a Multi Agency Intermediary.




CST 2000
Crest Underwriting Limited is not itself an insurance company and does not underwrite any risk in respect of any policy arranged on the
basis
of the information contained or attached to this proposal form.




CST 2000                                                            1
This proposal must be completed by a Partner, Director or Principal of the Firm. If there is insufficient space to answer any
question use additional sheets on the Firm’s headed paper marking the appropriate question number for reference and attach
same to this form.


1. Your business details
1.1   Name of the Individual or Firm requiring cover:




1.2   Date Firm established




1.3   Is the Individual or Firm currently trading




1.4   Title (s) of any former Practice(s), dates established and activities in which involved




1.5   Principal address:




      Other addresses from which the Individual or Firm operate



      Website address:



1.6   Please provide a full description of your activities



      ( Please also provide copies of any current brochures or printed literature utilised by your firm for marketing purposes.)




CST 2000                                                            1
1.7   Please provide details of membership of any association or professional body




1.8   Is the Firm or individual a member of a consortium or joint venture.                 Yes     No

      Is cover required for any joint venture.                                             Yes     No

      If “Yes” please provide full details;




2. You and your staff
2.1   Please provide details of all partners, principals and directors;

            Names                         Age      Professional Qualification       Number of years
                                                                                    relevant experience




2.2   Please indicate the number of:-

      (a)   Qualified Staff                                         (b) Trainee Staff
      (c)   Draughtsman                                             (d) Typists/General Administration
      (e)   All Other Staff

2.3   If you are a sole practitioner please confirm;

      a)    That the application for professional Indemnity is in relation to your full time occupation

            Yes     No

      b)    You have arrangements in place in the event of sickness or holidays to ensure the continuation of the
            business

            Yes     No




CST 2000                                                  2
2.4   If the Firm was established within the past twelve months please provide the following details in
      respect of each partner, principle and director;

      a)    Name(s) of the Firm(s) in which previously worked during the three year period prior to joining the
            Firm detailed in answer to question 1.1



      b)    The capacity employed in the firm(s) during that period




      c)    The type of projects involved in during that period




2.5   Has any partner, principal or director or employee ever been subject to disciplinary proceedings by any
      Association or Professional body.

      Yes     No

      If “Yes” please provide details;



2.6   Is the Firm, or any partner or director, individually connected or associated (financially or otherwise)
      with any other firm or organisation for whom work may be undertaken by the proposer?

      Yes     No

      If “Yes” please provide details;




3. Financial information
3.1   Please provide a split of the Gross Fees (excluding VAT) in your local currency specifying same, of
      the Firm from clients domiciled in;

                                           Date      Ireland       UK         Other                  Total
 a) Last completed financial year ending             €                                           €
 b) Current financial year ending                    €                                           €
 c) Forthcoming financial year ending                €                                           €

      Note: Figures must INCLUDE all amounts paid by the Firm to consultants to whom work was sub-contracted.




CST 2000                                                 3
3.2   Is more than 50% of the Firm’s annual fee income derived from either a single contract or a single client?

      Yes     No

      If “Yes” please provide details




4. Your business analysed
4.1   Please provide the approximate split of work undertaken by the Firm for the last financial year between the
      following disciplines;

      a)    Aborted work                                                                         %
      b)    Architecture – residential                                                           %
      c)    Architecture – commercial                                                            %
      d)    Building surveys non-structural/land surveys                                         %
      e)    Building surveys structural                                                          %
      f)    Civil/Structural engineering                                                         %
      g)    Electrical / heating & ventilation engineering                                       %
      h)    Environmental work                                                                   %
      i)    Feasibility studies                                                                  %
      j)    Interior design / refurbishment (non-structural)                                     %
      k)    Mechanical engineering                                                               %
      l)    Planning supervision                                                                 %
      m)    Project management                                                                   %
      n)    Restoration (non-structural)                                                         %
      o)    Soil engineering / site investigation / setting out                                  %
      p)    Town planning / landscape design                                                     %
      q)    Quantity Surveying                                                                   %
      r)    Structual Surveys, Inspection Reports and Valuations                                 %
      s)    Other work (please provide details)                                                  %

      ___________________________________________________________________________
           Total                                                               %

4.2   Please provide the approximate split of work undertaken by the Firm for the last financial year between the
      following contract types;

      a)    Amusement ride contracts                                                             %
      b)    Aviation/automotive/military/marine related engineering                              %
      c)    Bridges / tunnels / damns / mines / harbours/ piers / jetties                        %
      d)    Chemical / oil / nuclear engineering                                                 %
      e)    Cladding & curtain walling contracts                                                 %
      f)    Demolition contracts / non-destructive testing                                       %
      g)    Flooring / roofing contracts                                                         %
      h)    Foundations / underpinning / piling                                                  %
      i)    Fire protection / security related systems                                           %


CST 2000                                                 4
      j)    High rise buildings (over 6 storeys)                                                   %
      k)    Leisure contracts (excluding swimming pools)                                           %
      l)    Lifting / bulk handling equipment                                                      %
      m)    Railway / airport related contracts                                                    %
      n)    Swimming Pools                                                                         %
      o)    Toxic Waste / asbestos / landfill                                                      %
      p)    Water / sewage systems                                                                 %


4.3   Please provide the approximate split of work undertaken by the Firm for the last financial year between the
      following categories types;

      a)    Housing                                                                                %
      b)    Churches / Cathedrals                                                                  %
      c)    Hospitals                                                                              %
      d)    Schools / Universities                                                                 %
      e)    Hotels / Restaurants / Nightclubs / Dancehalls                                         %
      f)    Auditoria / Stadiums                                                                   %


4.4   Please state the three largest contracts where construction has commenced in the past five years

      a)    Start Date          Completion Date          Total Contract Value            Firm’s Contract Value

            Description:




      b)    Start Date          Completion Date          Total Contract Value            Firm’s Contract Value

            Description:




      c)    Start Date          Completion Date          Total Contract Value            Firm’s Contract Value

            Description:




4.5   Please state the two largest contracts where construction is expected to commence shortly:

      a)    Start Date          Completion Date          Total Contract Value            Firm’s Contract Value

            Description;




CST 2000                                               5
      b)     Start Date              Completion Date               Total Contract Value      Firm’s Contract Value


             Description;




4.6   Does the Firm’s risk management procedures include;

      i)     Letters of engagement detailing the Firm’s scope of service for all contracts Yes       No

      ii)    Letters of non-engagement / engagement                                          Yes     No

      iii)   Diary system with daily back up                                                 Yes     No

      iv)    Do your standard contracts conditions limit your liability                      Yes     No
             (please provide a copy of your standard contract conditions)

4.7   Has the Firm undertaken in the past, or is there an intention to undertake in the future, any activity other
      than those disclosed in this Proposal?

      Yes      No

      If “Yes” please provide details:




5. Insurance History
5.1   Does the Firm currently have a Professional Indemnity policy in place

      Yes      No

      If “Yes”;
            i)     Who are the current insurers
            ii)    What is the expiry date
            iii)   What is the retroactive date
            iv)    What is the policy Excess


5.2   Has any application for Professional Indemnity insurance made by the Firm or any partner, principal or
      director ever been cancelled, declined, failed to provide renewal terms or had special terms imposed.

      Yes      No




CST 2000                                                          6
      If “Yes” please provide details;



5.3   Has any claim, whether successful or not, ever been made against the Firm or its predecessors or any past
      or present partner, principal, director or employee?

      Yes     No

      If “Yes” please provide details;




5.4   Are you or any partner, principal, director or employee AFTER FULL ENQUIRY aware of any
      circumstance or any circumstances which may give rise to a claim against the Firm or its predecessors or
      any past or present partner, principal, director or employee?

      Yes     No

      If “Yes” please provide details;




6. Insurance requirements
6.1   Please state the total limit of indemnity required

6.2   Please state the excess you wish to carry in respect of each and every claim (please note that a minimum
      excess will be determined by Underwriters although a higher excess would normally warrant a discount)




CST 2000                                                   7
Declaration

The information that you have provided in this proposal form and any additional information attached to same or
provided in connection with this proposal form will form the basis of your insurance policy, and any inaccuracy
in any such information may give Underwriters grounds to avoid your policy and/or to decline any claim
thereunder. It is important that you advise Underwriters of all material information, and that you inform them
immediately of any change in any material information provided to them in connection with your policy, or of
any material change in your circumstances. Please note if you are in doubt whether or not any information is
material it should be disclosed. Failure to disclose information may prejudice your rights in the event of a claim.

A material fact is one that is likely to influence Underwriters’ judgement and acceptance of your proposal. If
your proposal is a renewal of an existing policy, it should also include any change in the facts previously advised
to Underwriters.

I/We declare that the statements and particulars given in this Proposal are correct and that no material fact has
been omitted. I/We agree that this Proposal together with any other information supplied in connection therewith
shall form the basis of the contract.




Signature                                         Position                                 Date



…………………….                                         …………………….                                ……………………




CST 2000                                                 8

				
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posted:9/18/2011
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