Professional Indemnity Page 5
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7d. Do you have a documented quality assurance or risk management program which addresses your professional duty risk?
Please provide highlights of the program which you have implemented to reduce / manage risk related to
No
Yes
breach of professional duty.
e. Is there a principal/director/partner responsible for overseeing risk management within your practice?
Please provide details.
Claims and Circumstances
18. Please answer the following questions after enquiry within your organisation.
a. During the past 10 years has any claim been made, or has negligence been alleged, against any entity or individual to be insured
by this insurance (including any prior corporate entity and any of the present or former principals), or have any circumstances which
may give rise to a claim against any of these been notified to insurers?
No
Yes
Please give details
Year
Amount Paid and/
Insured With
Claimant
Nature of Problem
Notified
or Outstanding
b. Are there any circumstances not already notified to insurers which may give rise to a claim against any entity or individual to be
insured by this insurance (including any prior corporate entity and any of the present or former principals).
No
Yes
Please give details
Name of Practice and
Claimant
Nature of Problem
Estimate
Principal
c. Are there any claims against previous practices which have been identified in Questions 4 or 5 of this Proposal, which may give rise
to a claim against any entity or individual to be insured by this insurance (including any prior corporate entity and any of the present
or former principals).
No
Yes
Please give details
Amount Paid and/
Name of Practice and
Claimant
Nature of Problem
Principal
or Outstanding
d. Has any Principal or staff member ever been subject to disciplinary proceedings for professional misconduct?
No
Yes
Please give details
Amount Paid and/
Name of Practice and
Claimant
Nature of Problem
Principal/Staff member
or Outstanding
Cover Required
19. Please state:
a. Amount of preferred Total Sum Insured.
$
b. Amount of preferred excess (N.B. Your policy will be subject to a minimum excess).
$
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