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  Professional Indemnity Insurance Proposal Form architects and civil engineers (Annual Cover)

These proposal forms are not a proof of cover unless a written confirmation is given by our company.


I- General Data
1- Name of firm *
Mobile *
E-mail *
2- Address of head office *
3- Address of branch office(s) and name(s) of resident partner(s)
4- In which countries do you carry out projects
5- When was the firm established ?
6- During the past five years, has the name of the firm been changed or has any other firm purchased or any merger or consolidation taken place ?
 Yes     No
If so, please give full details
7- Details of all practising principals or partners
Name
Qualifications, dates qualified/total duration of professional experience
Position held in company and how long
8- Total number of principals, partners and staff (Number)
Technical
- Principals, partners or officers
- Other qualified engineers
- Surveyors
- Qualified architects
- Draughtsmen
- Trainee staff
- Other qualified staff (please specify)
Total non-technical / administration staff
9- Do you give work to independent firms, subcontractors and/or specialists ?
 Yes     No
if so, please state kind of work and percentage of fees .
(The professional liability of such independent forms is not covered under the proposed policy)
10- Are you financially connected with a client ?
 Yes     No
Name of client
11- Is a major part of the work carried out for only one client ?
 Yes     No
II- Nature and volume of your present and forseeable future activities
1- In which of the following professions is your firm engaged ?
a) Civil engineering   b) Structural engineering  
c) Mechanical engineering   d) Electrical engineering  
e) Heating and ventilating engineering   f) Chemical engineering  
g) Soil Engineering   h) Others, not shown (please specify)  
2- Division of the firm's activities (% of total fees)
a- Feasibility studies, reports, surveys, etc (please specify projects)
b- Bridges and/or tunnels and roads
c- Dams, rivers and ports/harbours, jetties
d- Mines, underground or subaqueous works
e- Airports
f- Sewerage schemes, water supply
g- Foundations and underpinning railway and subway
h- Water schemes, agricultural engineering
i- Nuclear or atomic projects
j- Chemical, petrochemical plants
k- Housing schemes
l- High-rise buildings
m- Schools, hospitals, municipal buildings
n- Industrialized system buildings
o- Mechanical plant and bulk handling equipment (including silos, etc.)
p- Other works including any specialist activities not shown above (specify which)
3- Responsibilities (% of total fees)
a- Design only
b- Supervision
c- Design and supervision
d- Project management (turn-key contract) (see also 111/3)
4- Construction values and fees
Past financial year Current financial year Estimate coming financial year
a- Construction Values
b- Gross fees received
5- List some of the largest and typical projects performed by your firm during the last five years (brief description including values and fees)
III- Further activities
1- Do you also concern yourself with the sale and administration of real estate ?
 Yes     No
2- Do you construct and sell houses and/or flats for your own account ?
 Yes     No
3- Do you act as a project manager or main contractor ?
 Yes     No
4- Are you an agent for goods used for construction or do you obtain commission from the sale or distribution of such goods ?
 Yes     No
What kind of goods ?
5- Are you connected with firms constructing houses and flats or with auxiliary firms to the building industry or with other firms as a
- Member of the board ?
 Yes     No
- Partner ?
 Yes     No
- Shareholder (more than 3%)
 Yes     No
Names of firms and activities
6- Do your activities include giving expert opinions ?
 Yes     No
Also for municipal and state authorities
 Yes     No
IV- Previous insurance / Previous claims
1- Have you previously been insured?
 Yes     No
If so, please specify.
  Name of insurer Policy period
Policy period
claims-made basis occurence basis
Limit of indemnity
1
2
3
4
5
2- Has a previous application been declined ?
 Yes     No
Has a previous insurance
a- Required increased premium ?
 Yes     No
b- Required special restrictions ?
 Yes     No
c- Been terminated / not been renewed by an insurer ?
 Yes     No
If so, please give detailed information.
3- Have any claims been made during the past five years against your firm ?
 Yes     No
If so, please advise amount and background of each claim
4- Is your firm aware of any circumstances or incidents which may result in a claim against your firm ?
 Yes     No
If so, please give details.
V- Indemnity required
1- Limit any one claim
2- Aggregate limit
3- Deductible each and every claim to be borne by insured
VI- Endorsements to basic cover
1- Extended claims reporting period
 Yes     No
2- Loss of documents
 Yes     No
If so, up to what amount ?
3- Incoming / Outgoing partners
a- Incoming partners
 Yes     No
b- Outgoing partners
 Yes     No
If this extension is required, please advise names of the partners and incoming / outgoing dates.
I/We declare that the statements and particulars in this proposal are true and that I/we have not misstated or suppressed any material facts. I/we agree that this proposal, together with other information supplied by me/us, shall form the basis of any contract of insurance effected thereon.
Signing this proposal form does not bind the proposer or underwriter to complete this insurance .
Date this               day of                 20

For and on behalf of _________________________________________(Insert name of form)

Signature of partner or principal ____________________________________
Please attach a brochure conserning your firm
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