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FS Register FRN 1029698

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13+ years specialist broking experience

Professional Indemnity Insurance – Quote Request

Please complete as much as possible. We’ll use this to obtain tailored professional indemnity insurance terms for your business.

Your details

Contact title *

Contact first name *

Contact surname *

Trading name *

Registered name (if different)

Correspondence address *

Postcode *

Telephone number *

Email address *

Website

Preferred contact method

Business details

Approx year business started trading

Legal status *

Date incorporated * As shown on your Companies House record. Required for limited companies and LLPs.

Main professional discipline / trade *

Other professional services carried out

Are you authorised / regulated by any professional body or regulator?

If yes, please give details (name of body, registration number if known)

Full description of activities * Describe exactly what you do, typical clients and type of work carried out.

Territories where you provide services

UK only EU / EEA Worldwide excl. USA/Canada USA / Canada

Staff & structure

Number of principals / partners / directors

Number of qualified professional staff

Number of other technical staff

Number of admin / clerical staff

Total annual wageroll £ Total gross annual salaries / drawings for all principals and staff.

Do you use sub-consultants?

If sub-consultants are used, approx annual £ subcontracted and how you check their PI cover

Fee income

Financial year end (day / month)

Last completed financial year – total gross fees £

Current financial year – estimated gross fees £

Next financial year – projected gross fees £

Last completed year – fee split UK (%)

Last completed year – fee split EU / EEA (%)

Last completed year – fee split rest of world excl. USA/Canada (%)

Last completed year – fee split USA / Canada (%)

Largest fee from any one client in last 12 months £

Approx % of fees from your largest single client

Contracts & work types

Average size of contract / assignment £

Largest single contract / assignment in last 5 years £

Standard contract terms used?

Approx % of work under your own standard terms

Approx % of work under clients’ terms

Do you ever accept contractual indemnities or hold harmless clauses?

If yes, please provide details

Risk management

Do you always confirm instructions in writing?

Do you use engagement letters / terms of business?

Do you maintain written records and file notes?

Quality control procedures (if any)

Cover required

Limit of indemnity required (any one claim)

If other limit required, please specify

Excess (policy deductible) preferred (if any)

Retroactive date required (if known) If you have had continuous PI cover, this is usually the date PI was first taken out.

Has PI cover been continuous since the retroactive date?

Claims & circumstances

Any PI claims or circumstances (paid or outstanding) in the last 10 years? *

If yes, please provide details Please include dates, brief description, amounts paid / reserved and current position.

Have you or any partner / director ever had insurance cancelled, declined, refused, or had special terms imposed, or any unspent criminal convictions? *

If yes, please provide full details

Have you or any partner / director ever been declared bankrupt or insolvent, entered liquidation or administration, or had any County Court Judgments (CCJs)? *

If yes, please provide full details

Current insurance (if applicable)

Current PI insurer

Policy renewal date

Current limit of indemnity

Current excess

Approximate annual PI premium £

Anything else we should know?

Additional information Any other details which 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.