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Engineers Professional Indemnity Insurance – Quote Request

Please complete as fully as you can. Where a question does not apply, enter "N/A". We'll use this to obtain tailored professional indemnity terms for your engineering practice. If you need more room for any answer, use the "Additional information" box at the end.

Your contact details

Contact name *

Contact position

Contact email *

Contact telephone *

Preferred contact method

General details

1. Insured / Proposer name *

2. Address of the principal office

Address *

Postcode *

Telephone no.

Fax no.

Website

3. In what year was the business established?

4. a) Please list all additional business entities (whether or not currently trading)

Insured name

Year established

Year of cessation

b) Do you require cover in respect of all past activities of the businesses listed in 4a?

5. Please list addresses of all other offices currently trading

Address

Postcode

6. Is the firm, or any Principal, Partner or Director, a member of a consortium, joint venture, single project partnership or group practice?

If yes, please supply details

7. 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)?

If yes, please supply details

8. a) Has the firm previously been insured for professional indemnity?

If yes, please supply details of previous cover

Renewal date

Limit of indemnity

Premium

Excess

Insurer name

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?

If yes, please supply details

Staff and partners

1. Details of any Partners, Principals or Directors

Name

Date of birth

Relevant qualifications

Year became partner / director

2. a) Is cover required for the professional activities of any Principal, Partner or Director prior to joining the business?

b) If yes, please supply details

Name

Name of previous business

Activities

Start date

Leave date

3. Number of permanent staff in the current business

Full time

Part time

Partners / Principals / Directors

Professionally qualified staff

All other staff

Total

Activities

1. a) Total gross income for the last 3 years, plus an estimate for the current and forthcoming years

Year ending

UK (£)

USA / Canada (£)

Elsewhere (£)

Total (£)

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. Percentage of earnings for the last financial year received from the following disciplines

Architectural (%)

Civil engineering (%)

Electrical engineering (%)

Fees paid away to independent specialist consultants (%)

Foundation / underpinning (%)

Heating / ventilation engineering (%)

Mechanical engineering (%)

Project co-ordination (%)

Project management (%)

Soil / environmental (%)

Structural engineering (%)

Other (%)

Other – please state

Current total: 0% (must equal 100%)

* If fees are paid away to independent specialist consultants, please add details in the "Additional information" box at the end.

4. Approximate percentage of earnings for the last financial year received from the following sectors

Bridges / tunnels (%)

Chemical / oil / nuclear facilities (%)

Dams / mines (%)

Educational facilities (%)

Harbours / jetties (%)

Housing (%)

Industrial facilities (%)

Leisure facilities (%)

Mechanical & bulk handling plant (%)

Medical facilities (%)

Office facilities (%)

Offshore installations / marine (%)

Retail facilities (%)

Roads / highways (%)

Sewerage / water schemes (%)

Other (%)

Other – please state

Current total: 0% (must equal 100%)

5. a) Your five largest contracts where construction has commenced during the past 6 years

Location & description of contract

Total contract value

Your fee

Date commenced

Estimated completion date

b) Your three largest new projects where construction is likely to commence in the coming 12 months

Location & description of contract

Total contract value

Your fee

Date commenced

Estimated completion date

6. a) Do you use independent specialist consultants?

If yes, please supply details

b) Do you require them to carry a minimum level of professional indemnity cover?

If yes, please supply details

7. Do you envisage any material change in your activities in the next 12 months?

If yes, please supply details

Claims information

1. After enquiry, have any professional indemnity claims ever been made against the firm(s), any predecessors, or any current or retired Partners, Principals or Directors (individually or otherwise) for negligence, error, omission, breach of professional duty or the like — whether successful or not?

If yes, please provide details

Date of claim

Open / closed

Claimant

Details of claim / circumstance, including any payments made

2. After enquiry, are any of the Partners, Principals or Directors aware of any pending claims, or of any circumstances which may give rise to a professional indemnity claim against the firm(s), any predecessors, or any current or retired Partners, Principals or Directors?

If yes, please provide details

Date of claim

Claimant

Details of claim / circumstance, including potential value

Declaration

I/We declare that a fair representation of the risk has been made, by disclosing all material matters which I/we know or ought to know, or — failing that — by providing sufficient information to put a prudent insurer on notice that it needs to make further enquiries to reveal material circumstances. I/We understand that if the practice acquires, merges with or absorbs another practice during the period of insurance, the insurer will require similar information and may charge an additional premium. Submitting this form does not bind the proposer to complete the insurance, and an indication of terms may be provided on this basis. An original signature will be required before a contract of insurance can be made.

Print name *

On behalf of

Date *

Anything else we should know?

Additional information Use this box for any answer that needed more room, or anything else that may help us obtain the most competitive terms for you.

Fields marked with * are required.

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.

Office: Vivian House, Roman Bridge Close, Mumbles, Swansea, SA3 5BG

Call 01792 001350

Email: [email protected]

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Miller & Partner is an Authorised Representative of Gauntlet Risk Management Ltd and are authorised and regulated by the Financial Conduct Authority (FCA) under firm reference number 1029698. You may check this on the Financial Services Register by visiting the FCA website, https://www.fca.org.uk/firms/financial-services-register or by contacting the FCA on 0800 111 6768 Privacy Policy