Professional Indemnity Insurance
Proposal Form
IMPORTANT:
This proposal for insurance will be the basis of any subsequent insurance policy that we issue to you. It is essential that you answer fully
and accurately all the questions contained in this proposal, and that you provide us with any and all additional information relevant to the
risk to be insured for our decision as to the acceptance of the risk or the terms upon which it should be accepted. You failure to comply with
this obligation now may result in the rejection of your claim and the avoidance of your policy when a claim is made. If you are in any doubt
about the information to be given, please seek the advice and guidance of your insurance adviser or agent. If there is insufficient space in
this proposal form for you to provide relevant information, whether as requested or otherwise, please attach a separate sheet to this proposal
form and return it to us.
1 Name of Firm
2 Correspondence address of office
3 Address of all other offices
4 State nature of the profession / business including
full details of activities undertaken and any
intended change in these
5 When was Firm established
6 Give details of partners/directors/sole practitioner
Name Qualifications Date Qualified Number of years in this
capacity with Proposer
Technical Staff :
7 State number of permanent staff
Non-Technical Staff :
8 Does the proposer or any partner / director act on behalf of or undertake for work for any company or
business
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a) which forms part of the same group of
companies or businesses as the Proposer
(e.g. subsidiary, associate, parent) Yes No
or
b) in which the Proposer or any partner /
director has a financial interest and is able to
take or influence major policy decisions in Yes No
such company or business
If ‘Yes’ in either case, please give details
9 State the dates of the financial year
10 State the gross fees for the last and current financial year (including those paid to sub-contractors)
payable by clients. If the business is newly established, state the estimated gross fees for the
forthcoming year. For any non-fee earning business / practice, state total turnover.
Current Financial Year
Last Financial Year (Estimate)
i) In territory where domiciled
ii) In the USA/Canada or elsewhere for clients
whose address is in the USA/Canada
iii) Elsewhere
Total
11 Is the Proposer represented in any way in the Yes No
USA or Canada?
If ‘Yes’, state how (e.g. by subsidiary company, local office, local representative or by any other person
or concern holding a power of attorney on behalf of the Proposer)
Current Financial Year
12 State Last Financial Year (Estimate)
a) gross fees paid to sub-contractors
b) largest fee earned from any client
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13 Does the Proposer currently hold any Professional Yes No
Indemnity Insurance?
If ‘Yes’ state Renewal Date :
Limit of Indemnity :
Retroactive Date :
14 a) Is cover required for Partners’ Previous
Business? Yes No
If ‘Yes’, state
Name of Partner Title of Previous Business Dates with Previous Business
b) Please indicate if the following covers are required
i) Loss of Documents Yes No
If ‘Yes’, does the Proposer keep documents in fire
proof cabinets? Yes No
ii) Libel and Slander Yes No
iii) Dishonesty of Employees Yes No
15 Has any insurer in respect of the risks to which this proposal relates ever
a) declined a proposal, refused renewal or
terminated an insurance? Yes No
b) required an increased premium or imposed
special conditions? Yes No
If ‘Yes’ in either case, please give details
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16 a) Has any claim been made against the
Proposer or any partner, director, consultant
or employee for neglect, error or omission in Yes No
relation to professional duties?
b) Has the Proposer or any partner, director,
consultant or employee incurred any other Yes No
loss or expense which might be within the
terms of the cover?
If ‘Yes’ in either case, please give details separately of the circumstances of each incident including any
amounts paid and the estimated potential cost of the incident.
17 Is the Proposer of any principal, consultant or employee, after enquiry, aware of any circumstances
which might
a) give rise to a claim against the Proposer or
his predecessors in business or any of the
present or former partners or principals? Yes No
b) result in the Proposer or his predecessors in
business or any of the present or former
partners or principals incurring any losses or
expenses which might be within the terms of Yes No
the cover?
c) otherwise affect the Insurer’s consideration of
this insurance? Yes No
If ‘Yes’, please give details separately
18 What is the amount of Indemnity required?
Please state any alternative amounts for which a
quotation is required
19 Please state the amount the Proposer wish to
contribute towards each and every claim
Please state any alternative amounts for which a
quotation is required
Declaration
I/We warrant that the above statements made by me/us or on my/our behalf are true and complete and I/We
agree that this proposal shall be the basis of the contract between me/us and the Company. I/We agree to
accept a policy in the Company’s usual form for this class of insurance.
________________________ ________________________ ________________________
Signature of Partner / Director Company Stamp Date
Note – Signing this form does not bind the Proposer to complete the insurance.
PROHIBITION OF REBATES
1. No person shall allow or offer either directly or indirectly as an inducement to any person to take out or
renew or continue an insurance in respect of any kind of risk relating to lives or property in India, any
rebate of the whole or part of the commission payable or any rebate of the premium shown on the policy
nor shall any person taking out or renewing or continuing a policy accept rebate except such rebate as
may be allowed in accordance with the published prospectuses or tables of the insurer.
2. Any person making default in complying with the provision of this Section shall be punishable with fine which may
extend to five hundred rupees.
