Professional Indemnity Form - Consort Insurance Limited

1. Full Name

2. Email Address

3. Contact Number

4. Please confirm your IFSM membership tier level:

5. Please confirm your IFSM membership number:

This Proposal Form and all materials submitted shall be held in confidence. Please answer all questions in full and provide all requested information and/or required attachments to enable a quotation or indication to be provided. The completion and submission of this form does not bind the applicant or underwriters to enter into any contract of insurance.

If a question does not apply, please write “N/A”. If the answer is none, state “none” or “0”. If more space is needed, please continue on a separate sheet of the applicant’s letterhead and indicate the question number to which the information responds. This Proposal Form and any separate continuation sheets must be completed, signed and dated by a principal of the business.

6. Proposer Name – Please provide full name of Proposer(s), including trading name

7. Correspondence Address – Please provide postal address:

8. Company Website

9. Company Registration Number

10. Incorporation Date – Please provide the date the business was established:

11. Individual Experience(s) – Please list the names, date of birth, position, and sector experience of all Directors and/or Partners of the Proposer(s)

Individual Name

Company Position

Date of Birth

Qualifications

Years of sector experience

12. Business Description – Please provide a comprehensive overview of the activities undertaken within your business

13. Subsidiaries – Please provide all and any subsidiary companies to be insured:

14. Please state total number of:

Principals/Directors

Trained Staff

Qualified Staff

Other

15. Please list the professional/regulatory bodies, trade associations or societies to which you belong:

14. Please state gross fees (£) in the columns provided for the last 5 complete financial years:

Year End

UK work

Europe

Overseas

Total

Current year (est)

Last complete year

1 year prior

2 years prior

3 years prior

If ‘Overseas’ is selected, please specify the territory:

Please state the month of Financial Year End

15. Please provide breakdown of Turnover as follows:

Turnover details

Turnover where you design and install from your own design, whilst providing full technical supervision

Turnover where you accept full design responsibility but sub-contract both design and installation to BFSC

Turnover where you provide design and technical services but are not involved in installation

Turnover where you provide installation services with a third party to provide design and technical supervision on your behalf

Turnover where your provide installation services only i.e. pure contracting activity

Turnover where you provide maintenance services only

Turnover where you provide inspection, testing or certification services

Turnover where you provide training services

Other turnover not mentioned above

Total turnover

Next 12 months (£)

Last 12 months (£)

18. Division of Works: Environment – Please specify the percentage of gross fees in the previous year that the following types of work represent:

Types of Work

Percentage (%)

Example Works

Home Building

Individual Dwelling

Low Rise Multiple Dwellings (under 5 storeys)

High Rise Multiple Dwellings (over 5 storeys)*

Modular Dwellings

Engineering Construction

Highways

Bridges, Tunnels and Dams

Railways, Airports, Harbours and Jetties

Sewerage / Water Schemes

Industrial / Hazardous Locations

Power Plants

Refiners and Petrochemical Installations

Manufacturing Plants

Industrialised Systems Buildings

Airside

Offshore

Trackside

Chemical / Gas Works

Animal Laboratory Sites

Prisons

Detention Sites

Landfill Sites

Embassies

M.O.D Work

Amenities

Hospitals and Nursing Homes

Schools and Universities

Hotels and Recreation Centres

IT and Telecommunications

Car Parks

Other or Specialist Construction

Commercial / Retail

Shop

Office

Wholesale Distribution Centres

Retail Parks

* Please refer to Question 18.

19. High Rise Buildings

Have you worked upon, are working upon or intend to work upon a project greater than 5 storeys and/or 18 metres?

Yes

No

If so, please state the maximum storeys and metres you have worked to:

20. Division of Works: Disciplines – Please give an approximate percentage split of the disciplines within your Design and Contract Department (even if such work is sub – contracted):

Discipline

Active Fire Protection

Passive Fire Protection

Fire Alarm Systems

Structural Engineering

Mechanical Engineering

Electrical Engineering

Civil Engineering

(%)

Discipline

Fire Risk Assessments

Fire Risk Appraisal of External Walls (Fraew)

Interior Design

Principal Designer

Heating and Ventilation

Building Surveying

Other (If more than 10% please provide details)

(%)

Details of other disciplines over 10%

27. Please provide the following details:

Renewal Date

Total Limit of Indemnity (£)

Excess

Total Premium

Current Insurer

Retroactive date

Retroactive Date
A Retroactive Date is the date from which you have held uninterrupted Professional Indemnity insurance cover, even if you’ve changed insurers during this time, or a date in the past from which your insurer has agreed to cover you. Any claims that arise from events prior to this date is not covered by your insurance.

28. Please specify: The limit(s) of indemnity you require quotations for.

29. During the past 6 years:

a. Has any claim been made against you, whether successful or not, in respect of the risks to which this proposal form relates?

Yes

No

b. Have any complaints been made against you or have any disciplinary proceedings been brought by any Regulatory Body?

Yes

No

c. Have you become aware of any fraud and/or dishonesty on the part of any Partner/ Previous Partner(s)/Principal/Director/Member, consultant or employee of the firm?

Yes

No

If ‘Yes’ to any of the above, please provide full details including details of amount claimed for/lost including costs and expenses, Insurer reserve, details of the applicable policy excess and extent of allegations made.

25. After full enquiry are you aware of any circumstances which may or is likely to give rise to a potential claim or request for indemnity under the policy?

Yes

No

If ‘Yes’ please provide full details including amount claimed for/lost:

31. Declaration

I/we declare that I/we have made a fair presentation of the risk, by disclosing all material matters which I/we know or ought to know or, failing that, by giving the Insurer sufficient information to put a prudent insurer on notice that it needs to make further inquiries in order to reveal material circumstances.

Name (please print)

Position in Company

Signed

Date

32. Please upload the following documentation

Current policy document set*

Terms of business

IFSM membership level certificate

This field should be left blank

Professional Indemnity

11. Individual Experience(s) – Please list the names, date of birth, position, and sector experience of all Directors and/or Partners of the Proposer(s)

14. Please state total number of:

14. Please state gross fees (£) in the columns provided for the last 5 complete financial years:

15. Please provide breakdown of Turnover as follows:

18. Division of Works: Environment – Please specify the percentage of gross fees in the previous year that the following types of work represent:

Home Building

Engineering Construction

Industrial / Hazardous Locations

Amenities

Commercial / Retail

19. High Rise Buildings

20. Division of Works: Disciplines – Please give an approximate percentage split of the disciplines within your Design and Contract Department (even if such work is sub – contracted):

21. Risk Management – Please confirm:

22. Do you use the services of consultants, sub-contractors or agents?

25. Do you have standard terms of business for use with all clients?

26. Do you limit your liability for consequential loss under your Terms of Business?

27. Please provide the following details:

29. During the past 6 years:

31. Declaration

32. Please upload the following documentation