AAO Pana Insurance Brokers Sdn Bhd
29-1, Dataran Prima Business Centre, Jalan PJU 1/41, 47301 Petaling Jaya Tel : 03-7880 9277 Fax : 03-7880 8689
Web site : www.aaogroup.com
PROFESSIONAL INDEMNITY PROPOSAL FORM LAWYERS
IMPORTANT NOTICE
Pursuant to Section 149(4) of the Insurance Act 1996, you are to disclose in this proposal form, fully and recover in the event of a claim or allow the Insurer to void the Policy.
GENERAL INFORMATION 1. Name of Practice
2. Address of Practice
(If more than one, please state every address and indicate principal or partner responsible at each address)
3. Date of Commencement of Practice
4. Has the name of the Practice been changed, any other business
purchased or any merger or consolidation taken place during the YES NO past five years?
If YES, please give details:
5. What professional association, if any, does the Practice belong to?
6. What are the dates of the financial year of the Practice? From To
7. What are the gross fees for :
a) 12 months prior (audited) RM
faithfully all the facts which you know or ought to know, otherwise you could prejudice your rights to
8. Does the business of the Practice extend to or has it ever been extended
to activities in foreign countries? YES NO
If YES, please indicate the approximate percentage of gross fees derived:
a) from domestic activities %
b) from foreign activities %
Total: 100%
c) Name the foreign countries
d) State method of handling such business
9. Indicate the approximate percentage of gross fees derived from the Approximate percentage
following activities: (if none, state "NONE")
a) Real Estate Conveyancing %
b) Litigation %
c) Estate work %
d) Commercial matters %
e) Divorce %
f) Corporate %
g) Patents %
h) Any others (please give details) %
Total: 100%
PERSONNEL
10. Practising Partners or Principals
Name Qualification & How long practising in Date Qualified this Practice
11. Former, retired or deceased Partners:
Name Date of Joining this Practice
Date of leaving this Practice
12. Total number of practising Partners, Principals and staff Permanent Temporary a) Partners or Principals
b) Other equally qualified professionals
c) Staff other than typists, telephonists, receptionists, office boys and messengers
d) Typists, telephonists, receptionists, office boys and messengers
Total
13. Has any of those listed in question (10) ever been subject to
disciplinary action by the authorities as a result of their YES NO
professional activities?
If YES, please give details:
INSURANCE REQUIREMENTS
14. Specify the Limit of Indemnity required
(Give alternatives if required) RM
RM
RM
15. What amount of Excess would the Practice would be prepared to
carry in respect of each claim? RM
(A minimum excess is required depending on the size of firm RM and indemnity limit selected)
RM
16. Does the Practice require indemnity of any or all of the following extensions for which extra premium is required?
16.1 Retroactive Cover Extension
Do you require this extension? YES NO
Retroactive date requried
16.2 Partners' Previous Business Extension Do you require insurance for partners?
a) Incoming partners YES NO
16.3 Loss of Documents Extension
Do you require this extension? YES NO
If YES, do you keep documents in fire-proof cabinets / safes? YES NO
Please describe storage if other than fire-proof cabinets / safes.
What limit of cover as a percentage of the total limit insured 10% 20%
do you require? 50% 100%
16.4 Libel and Slander Extension
Do you require this extension? YES NO
If YES, please give details of claim(s) made against your firm involving libel & slander
What limit of cover as a percentage of the total limit insured 10% 20% do you require?
16.5 Dishonesty of Partners and Employees Extension Do you require this extension?
- for partners YES NO
- for employees YES NO
If YES, please answer the following:
a) Has the firm sustained any loss through fraud or dishonesty YES NO of any partner or employee?
b) Does the firm know of any fraud or dishonesty at any time of YES NO any present or former partner or employee?
c) Does the firm always obtain satisfactory reference when YES NO
engaging employees?
d) Are any employees allowed to sign cheques without YES NO
counter signature by a partner?
If answer to d) is YES, up to what amount?
e) Are cheques signed by the sole proprietor / partners pre-franked YES NO i.e. the amount in words and in figures duly made out in the
cheques prior to signing?
f) At what intervals are your clients' accounts audited?
g) Who are your accountants?
h) Who are your auditors?
If YES to question a) and/or b), please give details:
PREVIOUS COVERAGE
17.1 Has the Practice in the past been insured for professional liability risks?
If YES, please state: YES NO
a) Date of previous insurance b) Name of previous insurers c) Excess borne by firm d) Amount of indemnity e) Expiry date of policy
17.2 Is the Practice at present insured for professional liability risks?
If YES, please state: YES NO
a) Name of insurer b) Excess borne by firm c) Amount of indemnity d) Expiry date of policy e) Premium paid
18. Has any application for insurance on behalf of the Practice or its
predecessors in business or any of the present Partners or YES NO
Principals been declined or has any such insurance been cancelled or renewal refused or have special terms been imposed?
If YES, please give details:
19. Has any claim been made against or allegation of negligence
been made against the Practice or its predecessors in business YES NO or any of the present or former Partners or Principals?
If YES, state briefly the cause and nature of claim including the amount involved and names of the partner and the claimant, the date the claim was made, the date of the act giving rise to the claim, and the final disposition.
20. Are the Partners or Principals, after enquiry, aware of any
circumstances which may result in any claim being made against YES NO the firm, its predecessors in business or any of its present or
former partners or principals?
If YES, please give details:
SUPPLEMENTARY QUESTIONS ON EXCESS LAYER
21 Does the firm always use Letter of of Engagement / Letter of Instruction
in confirming and detailing the scope of all representations? YES NO
22 Does the firm always use Letter of of Engagement / Letter of Instruction
in confirming fees or billing rates for all representations? YES NO
23 Does the firm always confirm in writing when declining to represent
or accepting a matter? YES NO
24 Does the firm maintain a Calender / Docket Control System for all
litigation and non-litigation matters? YES NO
25 Please describe the firm's system of avoiding missed deadlines and due dates.
26 Does the firm maintain a conflict of interest avoidance system? YES NO
27 Does the firm disclose in writing any conflict of interest? YES NO
28 Does the firm obtain the written consent from each client represented
after disclosing a potential conflict of interest? YES NO
29 Has the firm acted as an adviser in any Merger or Acquisition within the past five years?
YES NO
If YES please provide the names of the parties whom the firm represented and the transaction value
30 Has the firm acted as an adviser in any Public Offering within the past five years?
YES NO
If YES please provide the names of the parties represented and the transaction value.
31 Has the firm acted as an adviser in any Global or American Depository Receipt YES NO Offering within the past five years?
If YES please provide the names of the parties represented and the transaction value.
32 Is there any partner or lawyer in the firm who is a director or company secretary for another company? If YES, please state the name of the other company, the nature of the
appointment, the primary operation of the other company, and whether the other company is also a client of the firm.
Declaration
21. I/We declare that the statements and particulars in this Proposal are true and that I/we have not misstated or suppressed any material facts. I/We agree that this Proposal, together with any other information supplied by
