pro-indemnity.co.uk Short Proposal Form For a quick indication of premium please complete this form and return it to us. Please note that we will only be able to approach one company for an estimate using this form. Also note that you will need to fill in the full form appropriate to your profession if you choose to go ahead, and at this time, you can elect for us to carry out a full market review.The completion of this form in no way binds the Proposer to purchase insurance, nor does it bind Underwriters to give insurance. Any information given will only be passed to Underwriters for the purpose of quotation and will be treated as confidential. If this proposal is in respect of a new business, it would help if you could also e-mail the CV's of all Principals, Partners and Directors to us at the address given at the foot of this form. Company Name: Address: Contact Phone: Date Established: E-Mail Address : Details of all Principals, Partners or Directors Name Age Qualifications UK USA/Canada Other Total Total Gross Fees in last financial year : £ £ £ £ Estimated Gross Fees for next financial year: £ £ £ £ Largest Fee from any one client: £ £ £ £ Full Description of Activities, with percentage breakdown (estimated if no historical data): % % % % % Details of the 3 largest contracts in the last 5 financial years (give details of current projects if new business): Client Description Contract Value Fee   Have any claims in respect of the risks to which this form relates ever been made against the business or any of the Principals, Partners or Directors? YesNo Are any of the Principals, Partners or Directors, AFTER FULL ENQUIRY, aware of any circumstance which might give rise to any such claim? YesNo Has any proposal in respect of the risks to which this form relates ever been declined or has any such insurance ever been cancelled or renewal refused? YesNo If you answered YES to any of the previous three questions, please provide details: Any other material information: Does the firm currently hold Professional Indemnity Insurance? YesNo What Limit of Indemnity do you require? Name of current insurers Name of current broker Renewal date Limit of indemnity Premium Excess I/we declare that, after full enquiry, the contents of this proposal are true and that I/we have not misstated, omitted or suppressed any material fact or information. I/we agree that this proposal together with any other information supplied by me/us shall form the basis of any contract of insurance which may be effected. If there is any material alteration to the facts and information which I/we have provided or any new material matter arises before the completion of the contract of insurance, I/we undertake to inform Underwriters. If this proposal is in respect of a new business, it would help if you could also e-mail the CV's of all Principals, Partners and Directors to us at chris@pro-indemnity.co.uk Enter name of Principal to agree to declaration: Date: Please supply me with an estimate within 105 working days. (We will attempt to meet the target, but please be aware that it does require our insurers to respond quickly as well!) Done Please check your details, and when you are happy that all is correct, tick the 'Done' box and click the Submit button above... Privacy : Any information given will only be passed to Underwriters for the purpose of quotation and will be treated as confidential. Click here for full details of our privacy policy.