Professional indemnity insurance Keychoice members scheme proposal form Instructions Please provide a full answer to every question. Please ensure that all answers are typewritten or printed in block letters within the spaces provided. A principal of the practice must sign and date this form and any separate sheets. 1 Name and address details Practice name (include all names under which you practice)
Main office address Telephone number
Contact e-mail address Postcode: Employer’s Reference Number (ERN) (found on PAYE documents)
Practice website
Date established
List number of branch offices
/
/
Please list on a separate sheet all branch offices including addresses for which you are seeking cover. 2 Staff Please advise number total number of staff Partners / Directors
Qualified
All Other Staff
3 Gross fees Please give the total gross commission / fee income for the last five years Last Financial Year
Year Ending
Year Ending
Year Ending
Year Ending
United Kingdom
£
£
£
£
£
Overseas
£
£
£
£
£
Total
£
£
£
£
£
Please state financial year end date
/
/
Estimated Income for current year
£
4 Insurances outside of UK Do you place any insurances for clients resident outside of the United Kingdom?
Yes
No
If ‘Yes’, please provide details below
Bluefin Professions | Keychoice members < £1m v2.0
5 Breakdown of commission / brokerage / fees Please specify the approximate percentage of the business’ gross commission/brokerage/fees derived from the following for the last complete financial year 1.
Personal Lines Insurance (including Motor)
%
2.
Commercial (excluding Motor)
%
3.
Commercial Motor
%
4.
Commercial Binding Authorities
%
5.
Aviation (Small Craft)
%
6.
Aviation (Other)
%
7.
Marine (Small Craft & Cargo)
%
8.
Marine (Other)
%
9.
Pensions
%
10.
Endowments
%
11.
Other Life
%
12.
Unit Trusts
%
13.
Other Investments
%
14.
All other work – Provide full details in the box below
%
Total
100%
If you have entered a figure within in categories 6, 8 or 14, please provide details below:
If you have ever undertaken work in categories 9-13, completion of a financial services questionnaire will be required – available to download at www.bluefinprofessions.co.uk/keychoice Are any substantial changes in the above percentages or are any major operations envisaged during the forthcoming year?
Yes
No
Yes
No
If ‘Yes’, please provide details below
Do you place more than 10% gross written premium with any one insurer? If ‘Yes’, please provide details below
6 Fire and perils 6.1
In respect of fire and perils, please give details of the two largest sums Insured that you place i.e. the material damage and business interruption combined exposure. Client
Risk
Sum Insured £ £
6.2
In respect of public liability, products liability, or professional indemnity risks, please give details of the two highest limits that you place. Client
Risk
Sum Insured £ £
6.3
In respect of property risks, give details of the two highest limits that you place. Client
Risk
Sum Insured £ £
7 Conditions precedent / warranties 7.1
Please provide details of the measures that are in place to alert clients to conditions precedent / warranties within policies
7.2
Are renewal terms discussed with clients prior to binding cover if changes are made to the previous years cover?
Yes
No
Yes
No
Yes
No
Yes
No
If ‘No’, provide confirmation of the measures in place to alert clients to changes.
7.3
Are transcripts of telephone calls relating to renewal terms retained in the event that written confirmation is not retained? If ‘No’, please provide details
8 Binding authorities Do you hold any discretionary or non-discretionary binding authority / claims handling authority with any insurer? If ‘Yes’, completion of a binding authority questionnaire will be required – available to download at www.bluefinprofessions.co.uk/keychoice 9 Claims and circumstances 9.1
Has any claim been made against the business or an employee of the business or any Partner, Director, Member or Consultant or their predecessors in business during the last ten years in respect of the type of liabilities to which this proposal relates? If ‘Yes’, please give details Date of Claim
Brief Details
Amount of Claims Paid £
Reserves Outstanding £
/
/
£
£
/
/
£
£
/
/
£
£
/
/
£
£
9.2
Has any action been taken to prevent a recurrence of a claim?
Yes
No
Yes
No
If ‘Yes’, please give details
9.3
After enquiry, are any of the business Partners / Directors / Members aware of any claim pending or any circumstance which might give rise to a claim against the business or any of the present or previous Partners, Directors or Members of the Business? If ‘Yes’, please give details
10 Quotation requirements Please give details of the firm’s current Professional Indemnity Insurance. Do not complete this question if you are already a client of Bluefin Limit of Indemnity
Excess
Premium
£
£
£
Name of Insurer
Renewal Date /
/
Please advise your requirements Option 1
Option 2
Option 3
Limit of Indemnity
£
£
£
Excess
£
£
£
Confirmation Disclosure of material facts It is essential that every Proposer or Insured when seeking a quotation, taking out or renewing an insurance, reveals to the prospective Insurers any material facts or information (including any material circumstances or change in circumstance) which might influence the judgement of Insurers in fixing the premium or in determining whether they will accept the risk. Failure to do so may render the contract of insurance voidable from inception at the option of the Insurers and enable them to repudiate liability thereunder. If you have any doubt as to what constitutes a material fact or circumstance, seek our advice. I declare that the above statements and particulars are true, full enquiry having been made, and I have not omitted, suppressed or misstated any material facts and undertake to inform the Insurer of any change to any material fact. I understand that the information provided will be used by the insurers and/or their agents to arrange and administer the insurance and in handling claims which may necessitate sharing information with third parties and that information may be shared with business partners to deliver any additional services provided with this insurance. I further agree that this declaration, together with any other information provided shall be the basis of any contract between me and the Insurer. A copy of this proposal should be retained by you for your own records This form must be signed by a principal of the firm Signature:
Date:
Print name:
Position:
/
/
Please return this application form along with any other supplementary information sheets to the address detailed below:-
Bluefin Professions | Castlemead | Lower Castle Street | Bristol | BS1 3AG t: 0117 929 3344 | f: 0845 521 5576 | e:
[email protected] | www.bluefinprofessions.co.uk
Bluefin Professions is a trading name of Bluefin Insurance Services Limited which is authorised and regulated by the Financial Services Authority. Registered Office: 5 Old Broad Street, London EC2N 1AD. Registered in England No: 931954 © 2012 Bluefin Insurance Services Limited
