Insurance Application

The purpose of this proposal form is for us to find out who you are and what you do. It does not oblige either party to enter into a contract of insurance. If a contract of insurance is agreed between us, this proposal form will form the basis of the contract.

Insurance is a contract of utmost good faith. This means the information you provide in this proposal form must be true and accurate. It also means you must tell us about all facts and matters which may be relevant to our consideration of your proposal for insurance. Any failure by you in this regard may entitle us to treat this insurance as if it never existed.

1.
a) About Your Business

Name of business*

Address*

Phone*

Email*

Website:

2. Associated and Subsidiary Companies

Please list these below

3. Your Business Activity

What are the current activities of your firm? (Please summarise what you do)*

4. Partners and Directors of Your Firm

i. Name*

ii. Name:

iii. Name:

5. Employees

Please provide total number of employees

6. Sub-contractors

Do you use independent sub-contractors?
YesNo

7. Your Turnover

We need to know your turnover including fee income and where it comes from. Please fill in the details below*

Total Turnover Including Fee Income for current year*

Total Turnover Including Fee Income for last year*

Please estimate the percentage split of your turnover including fee income separately for: UK/EU, USA/Canada, Rest of World and list below

8. Your Contracts

a) Please supply a copy of your standard client contract or terms of business

9. International Contracts

a) Do you agree to be bound by jurisdictions other than UK?
YesNo

10. Previous Insurance

a) Has any other insurer declined, refused to renew, or requested special terms to insure your business?
YesNo

11. Current Insurance

a) Do you currently have Professional Indemnity insurance?
YesNo

12. Claims Declaration

a) Has any claim been brought against you arising out of the performance of your business activities or has anyone threatened to bring such a claim?*
YesNo

b) Are you aware of any shortcoming in your work for a client which is likely to lead to a claim against you?*
YesNo

[This includes (i) a shortcoming known to you, but not your client, which you cannot reasonably put right; (iii) a complaint from your client about your work or anything you have supplied which cannot be immediately resolved; (iii) an escalating level of complaint from your client on a particular project; (iv) a client withholding payment due to you after any complaint.]

c) Have you suffered any loss from the dishonesty or malice of any employee or self-employed freelancer?*
YesNo

Do you have any grounds for suspecting that such a person has acted dishonestly or maliciously when working for you or on your behalf?*
YesNo

13. Material Information

Please provide us with details of any other information which may be relevant to our consideration of your proposal for insurance. If you have any doubt over whether something is relevant, please let us have details.

14. Declaration*

a) I/We declare that (1) this proposal form has been completed after proper enquiry; (2) its contents are true and accurate and (3) all facts and matters which may be relevant to the consideration of our proposal for insurance have been disclosed.

b) I/We undertake to inform you before any contract of insurance is concluded, if there is any material change to the information already provided or any new fact or matter arises which may be relevant to the consideration of our proposal for insurance.

c) I/We agree that this proposal form and all other written information which is provided are incorporated into and form the basis of any contract of insurance.


Signature of Principal/Partner/Director


Date

GDPR Agreement

Insurance Application

The purpose of this proposal form is for us to find out who you are and what you do. It does not oblige either party to enter into a contract of insurance. If a contract of insurance is agreed between us, this proposal form will form the basis of the contract.

Insurance is a contract of utmost good faith. This means the information you provide in this proposal form must be true and accurate. It also means you must tell us about all facts and matters which may be relevant to our consideration of your proposal for insurance. Any failure by you in this regard may entitle us to treat this insurance as if it never existed.

1.
a) About Your Business

Name of business*

Address*

Phone*

Email*

Website:

2. Associated and Subsidiary Companies

Please list these below

3. Your Business Activity

What are the current activities of your firm? (Please summarise what you do)*

4. Partners and Directors of Your Firm

i. Name*

ii. Name:

iii. Name:

5. Employees

Please provide total number of employees

6. Sub-contractors

Do you use independent sub-contractors?
YesNo

7. Your Turnover

We need to know your turnover including fee income and where it comes from. Please fill in the details below*

Total Turnover Including Fee Income for current year*

Total Turnover Including Fee Income for last year*

Please estimate the percentage split of your turnover including fee income separately for: UK/EU, USA/Canada, Rest of World and list below

8. Your Contracts

a) Please supply a copy of your standard client contract or terms of business

9. International Contracts

a) Do you agree to be bound by jurisdictions other than UK?
YesNo

10. Previous Insurance

a) Has any other insurer declined, refused to renew, or requested special terms to insure your business?
YesNo

11. Current Insurance

a) Do you currently have Professional Indemnity insurance?
YesNo

12. Claims Declaration

a) Has any claim been brought against you arising out of the performance of your business activities or has anyone threatened to bring such a claim?*
YesNo

b) Are you aware of any shortcoming in your work for a client which is likely to lead to a claim against you?*
YesNo

[This includes (i) a shortcoming known to you, but not your client, which you cannot reasonably put right; (iii) a complaint from your client about your work or anything you have supplied which cannot be immediately resolved; (iii) an escalating level of complaint from your client on a particular project; (iv) a client withholding payment due to you after any complaint.]

c) Have you suffered any loss from the dishonesty or malice of any employee or self-employed freelancer?*
YesNo

Do you have any grounds for suspecting that such a person has acted dishonestly or maliciously when working for you or on your behalf?*
YesNo

13. Material Information

Please provide us with details of any other information which may be relevant to our consideration of your proposal for insurance. If you have any doubt over whether something is relevant, please let us have details.

14. Declaration*

a) I/We declare that (1) this proposal form has been completed after proper enquiry; (2) its contents are true and accurate and (3) all facts and matters which may be relevant to the consideration of our proposal for insurance have been disclosed.

b) I/We undertake to inform you before any contract of insurance is concluded, if there is any material change to the information already provided or any new fact or matter arises which may be relevant to the consideration of our proposal for insurance.

c) I/We agree that this proposal form and all other written information which is provided are incorporated into and form the basis of any contract of insurance.


Signature of Principal/Partner/Director


Date

GDPR Agreement

Terms of Business | Privacy Policy
This Firm is authorised and regulated by the Financial Conduct Authority 305623
All content © 2019 Charles Milnes & Company Ltd
Site by oliver.tigwell.brown
Terms of Business | Privacy Policy
This Firm is authorised and regulated by the Financial Conduct Authority 305623
All content © 2019 Charles Milnes & Company Ltd
Site by oliver.tigwell.brown
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