16th May, 2008 | 14:32:47 BST

Proposal Forms

Professional Indemnity Form

ITIC Ltd, International House, 26 Creechurch
Lane, London EC3A 5BA.
Tel. +44 (0)20 7338 0150 Fax +44 (0)20 7338 0151
E-mail ITIC@thomasmiller.com
Website www.ITIC-insure.com

[Download this form in Word 6/95 format]

Company Name:

Main Activity:

Address:

Telephone:

Fax:

E-mail:

Insurance Broker to whom quotation should be sent:

1. General Information:

a)

Date established:

b)

Total no. of staff employed:

c) Name and address of any subsidiary, associated companies or branch offices which you wish to cover:

Name and Address:

Main activity:

d) Details of all Directors, Partners and Principals:

Names	Qualifications	Year Obtained	Length of time a Director, Partner or Principal

e) Please attach copies of relevant curriculum vitaes and brochures/literature on your company.

CV1 †

CV2 †

CV3 †

2. Business Activities:

a)

Please briefly describe the nature of your business:

b)

Please categorise your activities and indicate approximate gross income/fees from each for last year and the forecast for next year. Please state currency.

c)

Please name the principals for whom you regularly act:

d)

Are you involved in the manufacture, construction, alteration, repair or sale of products other than in a consultancy capacity? If YES, please supply details:

e)

Do you enter into any written agreement or operate under a standard form of contract? yes no

If YES please supply copies: †

f)

Are you a member of any Trade Association? If YES please state which:

3. Insurance Experience:

Please supply the following information:

a)

Name of current insurer:

b)

Limit of indemnity:

c)

Excess/deductible:

d)

Premium:

e)

Expiry date:

If currently not insured, please give details of most recent insurance:

4. Claims History:

Has any insurer:

a)

Declined to insure you: yes no

b)

Cancelled your insurance: yes no

c)

Refused to renew your insurance: yes no

d)

Imposed special terms: yes no

e)

Have any claims for professional negligence, successful or not, ever been made against your company or its present Directors?: yes no

If yes, please attach details here: †

5. Limits and deductibles:

Alternative 1

Limit

Deductible

Please state currency

Alternative 2

Limit

Deductible

Please state currency

6. Quality Assurance:

Have you obtained quality assurance accreditation in accordance with BS5750/ISO9002? yes no

7. Declaration:

I/We undertake that if this proposal is accepted I/We will act and abide and agree to be bound by the Rules of ITIC and any modification or alteration thereof made in accordance therewith from time to time by the decision of the Club and its Directors.

I/We declare that to the best of my/our knowledge and belief, the information given above is true and that I/We have not suppressed or misstated any material facts. (A material fact is one likely to influence the underwriter’s assessment of this proposal).

This proposal form must be completed by a person who is authorised to bind the proposer.

Name:

Position in company:

Date:

† The total aggregate size of all your attached files should not exceed 1Mb.

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