Accountants Professional Indemnity Proposal Form
The completion of this form in no way binds the Proposer to purchase insurance, nor does it bind Underwriters to give
insurance. Any information given will only be passed to Underwriters for the purpose of quotation and will be treated as
confidential.
1) / Companies to be insured: / Original Establishment Date:Main Address: / Telephone No:
Fax No:
Email:
Post Code: / Number of Offices:
2) / Details of all Principals, Partners, Directors
Name / Qualifications / Date Qualified
Partner 1:
Partner 2:
Partner 3:
Total Number of Employees Excluding Above:
3) / Financial Year End: /
UK
/USA/Canada
/Other
/Total
Total Gross Fees in last financial year : 1 / £ / £ / £ / £Total Gross Fees in previous financial year : 2 / £ / £ / £ / £
Estimated Gross Fees for next financial year: / £ / £ / £ / £
Largest Fee from any one client: / £ / £ / £ / £
4) / Full Description of Activities, with percentage breakdown (estimated if no historical data):
Accountancy and Compliance Tax for Quoted companies / %
Accountancy and Compliance Tax for NON Quoted companies / %
Accountancy and Compliance Tax for Sole Traders, Partnerships, Individuals / %
Audit for non-quoted companies / %
Audit for quoted companies / %
Other pure Tax work / %
Management Consultancy / %
Secretarial and Share Registration / %
Executorships and Trusteeships / %
Insolvencies, Liquidations and Receiverships / %
General Insurance Commissions / %
Stock Exchange Commissions / %
Commissions from investment business regulated under Financial Services Act / %
Directorships / %
Probate/Will-Writing / %
Computer Consultancy / %
Mergers, Acquisitions, Disposals / %
Other / %
5) / Do you undertake any work for Quoted Companies, clients in the Entertainment Industry, Lloyds of London or Lloyds managing agents? / YES / NO / If “Yes” please supply details on separate sheet
6) / Has the firm provided any advice in relation to tax planning schemes (company or personal) that could be considered as tax avoidance, even if only as an introducer? / YES / NO / If “Yes” please contact us for an additional questionnaire
7) / Details of the 3 largest clients in the last 5 financial years (give details of current projects if new business):
Client / Description of Work Undertaken for Client / Fee from Client
1
2
3
8) / Have any claims or circumstances in respect of the risks to which this form relates ever been notified to insurers or made against the business or any of the Principals, Partners or Directors whether successful or not? /
YES
/NO
Are any of the Principals, Partners or Directors, AFTER FULL ENQUIRY, aware of anycircumstance which might give rise to any such claim? /YES
/NO
Has any proposal in respect of the risks to which this form relates ever been declined or has any such insurance ever been cancelled or renewal refused? /YES
/NO
Has any person for whom insurance is now sought ever been the subject of disciplinary proceedings bythe I.C.A. or and other professional organisation? /YES
/NO
In the last complete financial year, did more than 20% of fee income derive from one client /YES
/NO
Is the Proposer/s authorised for investment business under the Financial Services Act? /YES
/NO
9) / Other Material Information:10) / Does the firm currently hold Professional Indemnity Insurance? /
YES
/NO
What Limit of Indemnity do you require? / £Name of Current Insurers
Name of your broker
Renewal Date
Limit of indemnity
Premium
Excess
11) / Does the firm have a facility for Tax Investigation Fee Protection Insurance for its clients? /
YES
/NO
IF Yes
Who is the Provider?Is this on a Master Policy (where you purchase policy for all of your clients) or sold per Client? / Master / Per Client
When is the facility due for renewal?
PLEASE READ THESE PARAGRAPHS CAREFULLY BEFORE SIGNING THE DECLARATION:
It is essential that every Proposer or Assured when seeking a quotation to take out or renew any insurance makes a fair presentation of their risk to the prospective insurer.
DUTY TO MAKE A FAIR PRESENTATION
You have a duty to make a fair presentation of the risk to be insured to the insurer. This requires the disclosure of any information which would influence the judgement of a prudent insurer in deciding whether to accept your insurance, impose special terms, or charge an increased premium.
A proposal or any other document relating to the contract of insurance, must be answered fully and accurately.All representations must be substantially correct if relating to matters of fact, or made in good faith if they are matters of expectation or belief. Please do consider the questions regarding “any other information” very carefully in the light of the duty of fair presentation.The provision and documentation of this information is your responsibility.
Please be aware that a failure to make a fair presentation of your risk may affect the payment of your claims, cause additional charges to be made by the insurer, or even invalidate the policy.
You are required to disclose what should “reasonably have been revealed by a reasonable search of information available to you”. Please note that this includes what is in the knowledge of all senior management within your organisation (senior officers not just directors), and what is known to other organisations.
Information must be disclosed in a way which is reasonably clear and accessible to a prudent insurer.
This duty arises not only at inception of the policy but also at renewal or in the event of any material change in your risk during the period of insurance.
If you have any doubt as to what constitutes a relevant fact or circumstance please do not hesitate to ask for advice.
DECLARATION
I/we declare that, after full enquiry, the contents of this proposal are true and that I/we have not misstated, omitted or suppressed any material circumstance or information. I/we agree that this proposal together with any other information supplied by me/us shall form our fair presentation of the risk to be insured. If there is any material alteration to the facts and information which I/we have provided or any new material matter arises before the completion of the contract of insurance, I/we undertake to inform Underwriters.
I/we hereby consent to any information I/we have provided being processed by you for the purposes of providing insurance and claims handling, which may necessitate sharing such information with third parties. Brunel Professions Limited may use this information for marketing (by post, telephone, e-mail or fax) subject to the conditions of the Data Protection Act. If you do not wish these details to be used for marketing please inform Brunel Professions Limited in writing. Under the Data Protection Act 1998 you have the right to access or amend the information we hold about you. If you would like to exercise either of these rights please contact Brunel Professions Limited.
Date: ………./………./……….
Signature of Principal ………………………………………………………………
Position within the company ………………………………………………………