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  Professional Indemnity Insurance Proposal Form Architects and Consulting Engineers(Project 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 *
 
Email *
Phone *
2- Address of head office *
3- Address of branch office(s) and name(s) of resident partner(s)
4- When was the firm established? *
5- Details of all practising principals or partners
Names
Qualifications, dates qualified/total duration of professional experience
Position held in company and how long
6- Total number of principals, partners and staff number
Technical
- Principals, partners or officers
- Other qualified engineers
- Qualified architects
- Surveyors
- Draughtsmen
- Other qualified staff(please specify)
- Trainee staff(please specify)
Total non-technical/administration staff
7- Do you give work to independent firms(subcontractors) and/or specialists? If so, please state kind of work and percentage of fees.(The professional liability of such independent firms is not covered under the proposed policy)
8- Are you financially connected with the principal of the project and/or with contractor/s ?
 yes    no
II- Nature of your 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- In what type of projects is your firm specialized ? Please specify.
3- List some of the largest and typical jobs performed by your firm during the last five years (brief description including values and fees)
III- General questions regarding the project
1- Principal
2- Main contractor/consortium
3- Nature and purpose of project
4- Location of project (place and country)
5- Total contract value (How much of total sum refers to building structure?)
6- Your fees
IV- Nature of your work/responsibility/period
1- Nature of your work (detailed description including special techniques and hazardous factors)
2- Your responsibility (e.g. design and/or supervision)
3- Commencement and duration of your work
4- Commencement and duration of construction work
5- Probable date of handing over
6- Period of your liability/statutory limitation
V- Technical details
1- Soil conditions
2- Ground-water conditions
3- Nature of foundations
VI- Surrounding properties
Please give description of the neighbourhood of the site (details of existing buildings or surrounding property possibly affected by contract works such as excavation, underpinning, piling, vibration or ground-water lowering)
VII- Insurance/claims experience
1- Are you protected by an annual professional indemnity insurance policy? If so, please advise (insurance company , limit of indemnity)
2- Number and amount of claims during the last 5 years
VIII- Indemnity required
1- Limit any one accident
2- Limit in the annual aggregate
3- Deductible each and every claim to be borne by insured
IX- Scope of coverage
1) Design only   2) Supervision only  
3) Design and supervision      
4) Loss of documents    
5) Dishonesty of employees? If so, please answer the following questions
  a) Has the firm sustained any loss through the fraud or dishonesty of any employee ?
 yes    no
  b) Is any employee allowed to sign cheques without countersignature by a partner?
 yes    no
6) Libel and slancler
 yes    no
I/We declare that the statement 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                 19

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

Signature of partner or principal ____________________________________
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