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Professional Indemnity

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13+ years specialist broking experience

Miscellaneous Professional Indemnity Insurance – Quote Request

Miscellaneous professional indemnity covers professions and consultancies that fall outside the standard classes. Please complete as fully as you can — the description of your professional services is the most important answer on this form, because it determines which insurers we can approach. Where a question does not apply, enter "N/A". If you need more room for any answer, use the "Additional information" box at the end.

Your contact details

Proposer first name *

Proposer last name *

Contact position

Company type *

Contact email *

Contact telephone *

Preferred contact method

General details

1. Insured / Proposer name *

2. Full description of the professional services you provide * Describe exactly what you do, what you advise on, what you are engaged to deliver, and anything a client relies on you for. Include any activity that could be seen as design, certification, inspection, valuation or the handling of client money.

Profession / trade description

Relevant qualifications, accreditations or professional body memberships

3. Address of the principal office

Address *

Postcode *

Telephone no.

Fax no.

Website

4. In what year was the business established?

5. 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 5a?

6. Please list addresses of all other offices currently trading

Address

Postcode

7. 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

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)?

If yes, please supply details

9. 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)

4. Percentage of earnings for the last financial year by type of activity

Consultancy / advisory work (%)

Design or specification work (%)

Project or programme management (%)

Training, coaching or education (%)

Inspection, survey, testing or certification (%)

Agency, intermediary or introducer work (%)

Recruitment or staff placement (%)

Marketing, media, PR or creative (%)

IT, software or technology services (%)

Research, analysis or reporting (%)

Expert witness or dispute support (%)

Fees paid away to sub-consultants (%)

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.

5. Approximate percentage of earnings for the last financial year by client sector

Private individuals (%)

Small and medium businesses (%)

Large corporates (%)

Public sector / local authority (%)

Banks, financial institutions or insurers (%)

Healthcare / medical (%)

Education (%)

Construction / property (%)

Energy, utilities or infrastructure (%)

Transport / aviation / marine (%)

Technology / telecoms (%)

Charities and not-for-profit (%)

Other (%)

Other – please state

Current total: 0% (must equal 100%)

6. a) Your five largest assignments in the last three years

Client & description of the work

Total value of the project / matter

Your fee

Date commenced

Completion date

b) Your three largest assignments expected to start in the coming 12 months

Client & description of the work

Total value of the project / matter

Your fee

Expected start date

Expected completion date

7. a) Do you use sub-consultants, associates or subcontractors?

If yes, please supply details

b) Do you require them to carry their own professional indemnity cover?

If yes, please supply details

8. 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 Ltd is an Appointed Representative of Gauntlet Risk Management Ltd, which is authorised and regulated by the Financial Conduct Authority (FRN 308081). Miller & Partner Ltd is entered on the Financial Services Register under firm reference number 1029698. You may check this on the Financial Services Register by visiting the FCA website at https://www.fca.org.uk/firms/financial-services-register or by contacting the FCA on 0800 111 6768. Miller & Partner Ltd is registered in England & Wales, company number 16206282. Registered office: 20 Vivian House, Roman Bridge Close, Swansea, SA3 5BG.