Professional Indemnity Proposal Form (Page 2 of 2) in pdf

Professional Indemnity Proposal Form Page 2

Details of the three largest contracts in the last five years (give details of current projects if new business):

CLIENT

DESCRIPTION

CONTRACT VALUE

FEE

i) Have any claims in respect of the risks to which this form relates ever been

YES

made against the business or any of the Principals, Partners or Directors?

ii) Are any Principals, Partners or Directors, AFTER FULL ENQUIRY aware of

YES

any circumstance which might give rise to such claim?

iii) Has any proposal in respect of the risks to which this form relates ever been

YES

declined or has any such insurance ever been cancelled or renewal refused?

If you have answered YES to any question, please provide details on a separate sheet.

Does the firm currently hold Professional Indemnity Insurance?

YES

i) Do you always have a written specification with your clients for each job

YES

which includes campaign details, volume, quality, timings and sign off procedures?

ii) Are all deviations to the above specification contract reported?

YES

iii) Do you always obtain final client sign off before going to print?

YES

If there is any other material information that you feel should be declared, please add on a separate

piece of paper.

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 affected. 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 Insurers.

Signature of

Principal: _________________________________

Date:___________________________

V1/10/09

V2/10/09

Professional Indemnity Proposal Form Page 2