1. Insured / Proposer name *
2. Address of the principal office
Address *
Postcode *
Telephone no.
Fax no.
Email
Website
3. In what year was the business established?
4. ICAEW Regulation No.
5. a) Please list all additional business entities (whether or not currently trading)
+ Add another entity
b) Do you require cover in respect of all past activities of the businesses listed in 5a?
Select...
Yes
No
6. Please list addresses of all other offices currently trading
+ Add another office
7. Is the firm, or any Principal, Partner or Director, a member of a consortium, joint venture, single project partnership or group practice?
Select...
Yes
No
If yes, please supply details
8. Does the firm, or any Principal, Partner or Director, carry out any work on behalf of another business in which they have a controlling or financial interest (other than as a shareholder in a public quoted company)?
Select...
Yes
No
If yes, please supply details
9. a) Has the firm previously been insured for professional indemnity?
Select...
Yes
No
If yes, please supply details of previous cover
+ Add another policy
b) In respect of professional indemnity insurance, has any insurer ever declined a proposal, declined to pay a claim, refused renewal, cancelled the insurance or imposed special conditions?
Select...
Yes
No
If yes, please supply details
1. a) Total gross income for the last 3 years, plus an estimate for the current and forthcoming years
2. Please specify the nature of the earnings declared in Question 1 from:
a) Territories subject to the law of the USA or Canada
b) Elsewhere (excluding UK, USA or Canada)
3. a) Largest total fee from one client in the last year (£)
b) Average fee per client in the last year (£)
4. a) Approximate percentage breakdown of your last financial year income / fees by category
Audit – quoted companies (%)
Audit – others (%)
General accountancy (%)
Company tax (%)
Compliance tax (%)
Taxation only (%)
Management consultancy (%)
Consultancy only (%)
Company secretary / register work (%)
Executorship and trusteeship (%)
Insolvencies, liquidations and receiverships (%)
Insurance, building society & stock exchange commissions (%)
Directorship fees (%)
Computer consultancy (%)
Corporate finance, mergers, acquisitions (%)
Investment advice (%)
Other (%)
Other – please state
Current total: 0% (must equal 100%)
b) Percentage of gross fees allocated to each client base (rounded to the nearest whole %)
Quoted companies * (%)
Banks, financial institutions, Lloyd's syndicates, insurance companies, underwriting agencies or offshore companies * (%)
Unquoted companies (%)
Unincorporated small businesses incl. sole traders and farmers (%)
Trust, pension schemes & charitable associations (%)
Individuals (%)
Others * (%)
Current total: 0% (must equal 100%)
* If you provide services to quoted companies, financial institutions/offshore companies, or "others", please add full details in the "Additional information" box at the end.
5. a) Does any one client generate 20% or more of your annual gross fee?
Select...
Yes
No
b) Do you provide, or have you provided, management services or investment advice to any entertainment clients or sporting professionals?
Select...
Yes
No
If yes to 5a) or 5b), please provide details of the client and the work undertaken
6. Do you act as auditors to any of the following?
a) Banks or other financial institutions?
Select...
Yes
No
b) Insurance companies or funds (including captive insurance companies)?
Select...
Yes
No
c) Any other "offshore" companies?
Select...
Yes
No
If yes to any of the above, please give details of the clients, the nature of work performed and your annual fee
7. Quality control procedures
a) How do you ensure that taxation deadlines are not missed?
b) What records are kept of telephone conversations and attendance at meetings?
8. Amount of indemnity required
Select...
£100,000
£250,000
£500,000
£1,000,000
£2,000,000
Other (please specify)
If other, please state (£)
9. Preferred level of self-insured excess (£)
A self-insured excess will apply to any claim. We'll set the minimum when assessing your risk — indicate a preferred level here if you have one.
By submitting this form you are providing consent for Miller & Partner Ltd to contact you in relation
to this quotation and any related insurance products.
