Business Consultants Professional Indemnity Insurance

Professional Indemnity Insurance for Business Consultants

Proposed policyholder’s full name:

Proposed policyholder’s business activity:

Proposed policyholder’s website: www.

If any other entities are to be covered, please list the names of such entities

Proposed policyholder’s main office address:

Postcode

Telephone

How long has the proposed policyholder been established.

Do at least 50% of the partners/directors have at least five years relevant experience?

Does the firm currently have professional indemnity insurance?

Does any one client represent more than 50% of the total income of the entities to be covered?

Is 20% or more of the total income of the entities to be covered paid to sub contractors?

Do the entities to be covered ensure that sub contractors are fully qualified and carry professional indemnity insurance? If No please give full details in the Additional Information Box below.

Has any insurer declined, cancelled or non-renewed any prior policy or application for professional indemnity or similar insurance of any of the entities to be covered? If Yes please give full details in the Additional Information Box below.

Has any entity to be covered sustained any loss due to fraud or dishonesty by an employee or third party or has any entity to be covered reason to suspect such activity? If Yes please give full details in the Additional Information Box below.

Has any entity to be covered been subject to any disciplinary or regulatory enquiry or proceedings or fines, penalties or other sanctions by a governmental, regulatory or professional body? If Yes please give full details in the Additional Information Box below.

Is any entity to be covered aware of any claim (whether insured or not) ever having been made against any entity to be covered or its predecessor? If Yes please give full details in the Additional Information Box below.

Is any entity to be covered aware of any facts or circumstances that may give rise to a claim against any entity to be covered or its predecessor? If Yes please give full details in the Additional Information Box below.

Names of partners and directors (CV if less than five years experience)

Full Name	Qualifications	Date Qualified	Number of years at the firm

Gross fee income for the last completed year:

Total fee Income

UK fee Income

Overseas fee income

(excl US & Canada)

US & Canada fee Income

Estimated Gross fee income for the forthcoming year:

Total fee Income

UK fee Income

Overseas fee income

(excl US & Canada)

US & Canada fee Income

Largest contracts/projects carried out by the firm in the last five years

Name of Client	Nature of project/contract	Total contract value	Income

Limit of Indemnity Required for Quotation- you may select more than one box

£100K£250K£500K£1M £2M £5M

Other

Additional Information Box

I declare and agree, on behalf of the proposed policyholder and all proposed insured's, that to the best of their knowledge and belief the statements set forth herein are true and that, if the Company agrees to insure, the material statements in this proposal or in any other information supplied, shall be the basis of the contract and shall be incorporated into and constitute part of the policy.

It is hereby agreed that the Company is authorised to make any investigation and inquiry in connection with this proposal that it deems necessary.

I Agree