Name of Insured / Proposed

Address

Tel Number

Mobile No

Fax No

Email

Date Business Established

Q1) If you are a sole Director or Principal:

Is this a part-time occupation: Yes No

If YES please give brief details of other part-time/full-time employment

Details of all Principals, Partners & Directors

Name	Age	Qualifications	Date Qualified	Number of years experience

If a principal has less than 5 years relevant experience, please email us a CV.

Q2) Do you currently have Professional Indemnity Insurance in force? Yes No

Current Insurer

Renewal Date

Premium

Number of Years continuously insured for PI (Please provide retroactive date)

This policy will not cover work undertaken prior to inception of the Policy unless the retroactive date has been advised.

Q3) Please list your largest 3 projects undertaken since business established:

Description / Country	Client	Commenced	Completed	Your fee	Total Value

What is the largest fee received in the last year and from which client:

Client	Fee

Your business activities

Please split your last complete financial year turnover between the following professional activities

Graphic Design	Fees
	Production Costs
Interior Design	Fees
	Production Costs
Product Design	Fees		please specify
	Production Costs
Corporate Identity	Fees
	Production Costs
Other please specify

Does the above split accurately reflect (a) your business activities in the past and (b) estimated business activities in the future? Yes No

Q4) Are you members of any Trade Association or Professional Body e.g. Chartered Society of Designers? Yes No

Please Specify

Please indicate the % of your work which is design only in comparison to project were you arrange for manufacture / production

Design Only projects % (turnover)

Do you wish to extend Cover to include:

(a) Infringement of  Intellectual Property Rights eg copyright	Yes No
(b) Breach of Confidentiality	Yes No
(c) Rectification (first party) Cover	Yes No
(d) Irrecoverable Fees Cover	Yes No
(e) Product Disparagement	Yes No

Do you always prepare a written specification for your client for each project incorporating “ signing off “ procedures? Yes No

Are all changes to the specification contract recorded? Yes No
Do you always obtain final client sign off before production? Yes No
(Please email us a copy of Standard Terms and Conditions)

Q5) Please give details of the Numbers of staff and projected payments to:

Principals/Partners
Clerical/ Sales Employees
Manual Employees
Labour Only Sub Contractors
Independent Sub Contractors

Q6) Business Relationships

Is the company or any individual connected or associated (financially or otherwise) with any other company or organisation for whom work may be undertaken for or in connection with the proposed? Yes No

If yes please provide full details

Are you a member of a consortium or engaged in any single project partnership? Yes No

If yes please give the names of the consortium or other members/partners and their capacities in the consortium/partnership. Full information will be required:

Do you require sub-consultants to carry Professional Indemnity Insurance? Yes No

Minimum Limit: £ % of fees paid to sub-consultants:

Underwriters retain rights of recourse against sub-contractors unless specifically agreed otherwise.

Q7) Limits of Indemnity - Please tick level required

Public/Products Liability Yes No
1 Million 2 Million

Professional Indemnity Standard Yes No
£100,000 £250,000 £500,000 £1,000,000

Employer Liability £10,000,000 Standard Level Yes No

Declaration

Has any Insurer every declined to offer renewal terms ,imposed special terms or cancelled Cover for the Firm or Principal, Partner or Director Yes No

Has any prosecution, prohibition notice or improvement order been made against you under the Health & Safety Legislation during the last 5 years. Yes No

Are any of your Principals/Partners aware “after full enquiry” of any circumstances, which may give rise to a Claim against the Firm. Yes No

Have any claims been made against you in the last 5 years (or pending) in respect or risks to be covered by the Insurance. Yes No

Are you aware of any shortcoming in your work for a client which is likely to lead to a claim against you? This includes (a) a shortcoming known to you, but not your client, which cannot reasonably put right (b) a compliant from your client about your work or anything you have supplied which cannot be immediately resolved (c) an escalating level of compliant from your client on a particular project (d) a client withholding payment due to you after any complaint. Yes No

If yes, please give full details i.e Date, Claimant, Type, Amount and current status etc.

IMPORTANT NOTICE CONCERNING DISCLOSURE

In completing this Proposal you must disclose all materials facts, i.e. those which an Insurer would regard as likely to influence the assessment or acceptance of the risk.  Failure to do so could invalidate the Insurance.  If you are in doubt as to what facts are material you should, for your own protection, disclose them.

I/We declare that to the best of my/our knowledge and belief the information given in this Proposal is true in every respect.

I/We agree that this Proposal should be the basis of the contract between me/us and the Company and to accept the Company’s Policy applicable to the Insurance.

I/We declare that if anything on this Proposal was written by another period he/she acted as my/own Agent for this purpose.

I agree with the above statements

To send your form, you must enter the PIN number below correctly into the box provided.

PIN Number