BDB (UK) Limited
40 Lime Street, London EC3M 7AW
PROFESSIONAL INDEMNITY INSURANCE
INSURANCE CONSULTANTS & FINANCIAL ADVISERS
PROPOSAL FORM
THIS PROPOSAL MUST BE SIGNED BY A PARTNER OR DIRECTOR OF THE BUSINESS. ALL QUESTIONS MUST BE ANSWERED AND ADDITIONAL INFORMATION PROVIDED WHEN REQUESTED TO ENABLE A QUOTATION TO BE GIVEN. THE COMPLETION AND SIGNATURE OF THIS PROPOSAL DOES NOT BIND THE PROPOSER OR THE COMPANY TO COMPLETE A CONTRACT OF INSURANCE
PLEASE USE AN ADDITIONAL SHEET OF PAPER WHERE NECESSARY TO PROVIDE COMPLETE ANSWERS TO ALL QUESTIONS
1 Name(s) under which business is conducted
2 Date business established 3 Address and Website Address
4 If more than one office exists, is there a senior partner/director at each office to oversee operations?
YES/NO If ‘NO’ please provide a curriculum vitae of the person overseeing each office
5 (a) Has the name of the business changed or have any mergers or acquisitions taken place during the past ten years? YES/NO If ‘YES’ please give details
(b) Is cover required for the above predecessor firms? YES/NO
6 Have the business activities changed substantially during the past ten years? YES/NO If ‘YES’ please give details
7 Please indicate the professional associations of which the business is a member
FSA AIFA
IIB
BIBA Others (Please state)
8 Give details of all partners/directors
Name Age Qualifications Date Qualified
How Long Practising as a Partner/Director
IF UNDER FIVE YEARS EXPERIENCE IN THIS OCCUPATION PLEASE SUPPLY A CURRICULUM VITAE
9 (a) Numbers of permanent staff (other than partners/directors in current business) Qualified
All others
(b) Does the Business have any Appointed Representatives? YES/NO
(c) Does the Business have any Self-Employed Consultants? YES/NO If “YES” to (b) or (c), please provide full details on your headed paper.
10 Please give the total gross commission/fee income for the past two years and forthcoming year generated from
LAST COMPLETE YEAR Year End ___/___/____
PREVIOUS YEAR Year End___/___/____
FORTHCOMING YEAR Year End ___/___/____
UK £ £ £
Overseas £ £ £
Total £ £ £
11 Please give details of any insurances placed for clients resident outside of the UK
12 Please give details of any insurances placed with insurers or underwriters who do not operate in the UK or who are not members of the ABI or Lloyds
13 (a) In respect of fire and perils, please give details of the two largest Sums Insured that you place ie, the material damage and business interruption combined exposure
Client Risk Sum Insured
(b) 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
14 Please specify the percentage of the business’ gross commission/brokerage/fees derived from the following:
Pensions _________%
Endowments _________%
Other Life _________%
Mortgages _________%
Building Society Agencies _________%
PHI Medical Insurance _________%
Pension Fund Managers, Trustees or Administrators _________% Private Client Portfolio Management – Discretionary YES/NO _________% Investment in Unit Trusts or Insurance Bonds _________% Dealing in Listed, Unlisted UK or Foreign Securities _________% Dealing in Bonds (eg Eurodollar), or Commodities _________% Investment in Tangibles (eg. Coins, Gems etc) _________%
Accountancy, Taxation _________%
Management Consultancy _________%
Mergers and Acquisitions/Corporate Finance _________%
Estate Agency _________%
Personal Lines Insurance (excluding Motor) _________% Commercial Insurance (excluding Motor) _________%
Motor Insurance _________%
Construction Insurance _________%
Professional Indemnity Insurance _________%
Aviation/Marine Insurance _________%
Other (please specify) _____________________________
_______________________________________________ _________% TOTAL
100%
15 For any of the categories in Question 15 is more than 50% of the business placed with
one Insurer? YES/NO
If “YES”, please give details
16 Please give details of the ‘other’ activities if applicable
17 Does the business operate any binding authority arrangement whereby an insurer or underwriter has granted the business authority to set rates terms and conditions and/or
to handle claims without referral? YES/NO
If ‘YES’ please complete the supplementary questionnaire
18 Please give details of the supervision procedures of junior staff (i.e., those with less than 2 years insurance experience) If not applicable please write N/A
19 (a) Has the business sustained any loss during the past ten years as a result of the fraud or dishonesty of any partner, director or employee of the business? YES/NO If ‘YES’ please give details
(b) Is any individual authorised to sign cheques as a sole signatory on behalf of
either the business or clients’ accounts? YES/NO
If ‘YES’ please give details, specifying limit
(c) How often are entries in cash books reconciled with bank statements by a partner/director or company secretary (other than the head cashier and/or chief bookkeeper)?
Weekly Monthly Quarterly
(d) Is there a complete annual audit by a firm of professional accountants? YES/NO (e) Are clients’ funds kept in properly designated clients’ accounts separate from the
accounts of the business? YES/NO
(f) Are satisfactory written references always obtained when engaging all new partners, directors, employees or self employed persons? YES/NO
20 Please give details of the firm’s professional indemnity insurance over the last three years
Limit of Indemnity
Insured’s Contribution (Excess)
Premium Name of Insurer Expiry Date of Policy
£ £ £
£ £ £
£ £ £
21 (a) What limit of indemnity is required?
(b) What contribution (excess) do you wish to pay
22 In respect of professional indemnity insurance, has any insurer ever declined a proposal, declined to pay a claim, refused renewal, cancelled such insurance or
imposed special conditions? YES/NO
If ‘YES’ please give details
23 Claims History
(a) Has any claim been made against the business or an employee of the business or any partner, director or consultant or their predecessors in business during the last ten years in respect of the type of liabilities to which this proposal relates?
YES/NO
If ‘YES’ please give details
Date of Claim Brief Details Amount of Claims Paid £
Reserves Outstanding £
(b) Has any action been taken to prevent a recurrence of a claim? YES/NO If ‘YES’ please give details
If ‘NO’ why not?
(c) After enquiry, are any of the business partners or directors 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 or directors of the business?
YES/NO If ‘YES’ please give details
(d) Have present insurers been notified of all claims including requests for a pension review and all circumstances, which may give rise to claims?
YES/NO If ‘NO’ please give details
(e) Have any disciplinary proceedings been brought by a regulatory or professional body against the business, any employee, self-employed consultant or any partner or director or their predecessors in business during the last ten years?
YES/NO If ‘YES’ please give details
Important Reminder: All claims/complaints and circumstance (i.e. potential claims) must be immediately reported to your existing insurer prior to expiry of your current policy.
Please advise any matters or circumstances which we might wish to take into account in determining whether to offer you insurance cover
Declaration
I/we declare that the above statements and particulars are true, full enquiry having been made, and I/we have not suppressed or mis-stated any material facts and undertake to inform the insurer of any change to any material fact
I/we agree that this declaration together with any other information shall be the basis of any contract between me/us and the insurer
Signature of Proposer (Partner/Director)
Name
For and on behalf of (Insert Name of Business/Firm)
Date
Please retain a copy of this completed proposal form for your records
