Professional Indemnity Insurance
Proposal Form
Certain Underwriters at Lloyd’s and/or Companies (Insurers) acting through their agent International Underwriting Agencies Ltd (“IUA”) PO Box 7238, Wellesley Street, Auckland 1010
IMPORTANT
Th is is a p r o p o sal f o r m f o r a claim s-m ad e Cer t if icat e.
Th e Cer t if icat e w ill o n ly r esp o n d t o claim s an d /o r cir cum st an ces w h ich ar e f ir st m ad e ag ain st yo u an d n o t if ied t o In t er n at io n al Un d er w r it in g Agen cies Lim it ed d u r in g t h e Cer t if icat e p er io d . Th e Cer t if icat e w ill n o t p r o vid e co ver f o r :
(a) Even t s t h at o ccu r r ed p r io r t o t h e r et r o act ive d at e o f t h e Cer t if icat e (if sp ecif ied ). (b ) Claim s m ad e af t er t h e exp ir y o f t h e Cer t if icat e p er io d (o r ext en d ed r ep o r t in g p er io d if
availab le) even t h o u g h t h e Wr o n g f u l Act g ivi n g r ise t o t h e claim m ay h ave o ccu r r ed d u r in g t h e Cer t if icat e p er io d .
(c) Claim s n o t if ied o r ar isin g o u t o f f act s o r cir cu m st an ces n o t if ied u n d er an y p r evio u s Cer t if icat e o r n o t ed o n t h e cu r r en t p r o p o sal f o r m o r an y p r evio u s p r o p o sal f o r m . (d ) Claim s m ad e, t h r eat en ed o r in t im at ed p r io r t o t h e co m m en cem en t o f t h e Cer t if icat e
p er io d .
(e) Fact s o r cir cu m st an ces in yo u r kn o w led ge p r io r t o t h e Cer t if icat e p er io d w h ich yo u kn ew h ad t h e p o t en t ial t o g ive r ise t o a claim u n d er t h e Cer t if icat e.
Th is p r o p o sal f o r m s t h e b asis o f an y in su r an ce co n t r act en t er ed in t o . Please co m p let e it f u lly an d car ef u lly, r em em b er in g t o sig n t h e Declar at io n . If yo u d o n o t h ave en o u g h r o o m , p lease at t ach ad d it io n al sh eet s.
Duty of Disclosure
Yo u h ave an o n g o in g d u t y t o d isclo se all Mat er ial Fact s an d f ailur e t o d o so co u ld p r eju d ice f u t u r e claim s. Mat er ial Fact s ar e t h o se w h ich m ay in f lu en ce a p r u d en t in su r er in d ecid in g w h et h er o r n o t t o in su r e yo u , o n w h at t er m s, an d at w h at p r em iu m .
Applicant details
Name of applicant including trading names, names of subsidiaries and any parties required to be insured:
Postal address:
Website address: Contact person:
Email address: Fax no:
CHRISTCHURCH P: +64 3 313 8435 F: +64 3 310 7685 Unit 11, 6-8 Cone Street, Rangiora 7400, New Zealand PO Box 774, Rangiora 7440
P: +64 9 914 6440 F: +64 9 302 7694 Level 9, 52 Swanson Street, Auckland 1010, New Zealand PO Box 7238, Wellesley Street, Auckland 1141
Business details
St at e t h e n at u r e o f t h e p r o f essio n /b u sin ess in cl u d in g a f u ll d escr i p t io n o f y o u r
act iv it ies an d in p ar t icu lar t h o se act iv it ies w h er e y o u p r o v id e ad v ice, d esig n o r o p in io n w h ich m ay b e r elied u p o n b y a t h ir d p ar t y :
Cat eg o r ize y o u r act iv it ies an d co n f ir m t h e p er cen t ag e o f y o u r t o t al in co m e (in clu d i n g am o u n t s p aid b y y o u t o su b co n t r act o r s o r co n su lt an t s) f o r y o u r cu r r en t y ear b y t h o se cat eg o r ies: Activity Percentage (a) % (b ) % (c) % (d ) % (e) % (f ) % Total 100%
In d icat e t h e n u m b er o f y ear s t h is b u sin ess h as b een :
Op er at in g : Ow n ed b y p r esen t o w n er s: Man ag ed b y p r esen t m an ag em en t : List all accr ed it at io n s an d asso ciat io n m em b er sh ip s h eld b y y o u r b u sin ess:
Risk management details
Hav e y o u im p lem en t ed f o r m al r isk m an ag em en t p r o ced u r es o r p lan s? Yes No If Yes, is ad h er en ce t o t h ese p r o ced u r es p er io d ically r ev iew ed an d ar e kn o w n b r each es
r ect if ied ? Yes No
If No , w o u ld y o u b e p r ep ar ed t o w o r k w it h In t er n at io n al Un d er w r it in g Ag en cies Gen er al In su r an ce (N.Z.) Lim it ed in est ab lish in g su ch p r o ced u r es? Yes No Ar e t h er e an y p ar t icu lar ch ar act er ist ics o f y o u r b u sin ess (e.g . r isk m an ag em en t p r act ices, p r o v isio n o f ser v ices t o sp ecialised m ar ket s et c) w h ich w o u ld m at er ially r ed u ce o r in cr ease y o u r exp o su r e t o p r o f essio n al liab ilit y claim s in co m p ar iso n t o p r act it io n er s in y o u r p r o f essio n g en er ally ? Yes No
If Yes, p lease p r o v id e d et ails:
Do y o u em p lo y leg al co u n sel o r r et ain a p ar t icu lar f ir m o f so licit o r s? Yes No If Yes, p lease p r o v id e d et ails:
Administration and staff
Please p r o v id e t h e f o llo w in g d et ails in r esp ect o f all cu r r en t p r in cip als, p ar t n er s an d d ir ect o r s:
Name Professional
qualifications Year qualified
Number of years as a Partner, Principal or
Director
Please p r o v id e t h e f o llo w in g d et ails in r esp ect o f all f o r m er p r in cip als, p ar t n er s an d d ir ect o r s:
Name Date left this business Reason for Leaving
In d icat e t h e n u m b er o f p er so n n el in each ap p licab le cat eg o r y :
Employees Contractors Full time Part time Full Time Part time
Pr in cip als, p ar t n er s an d d ir ect o r s Qu alif ied p r o f essio n als
Ad m in ist r at iv e an d cler ical Ot h er (d escr ib e)
Financial information
What is the date of your financial year-end?
Please pr o v ide g r o ss fees o r in co me (in clu ding fees paid to su bco n tr actor s) as fo llows:
Country Last Financial year Current financial year (estimate)
Next financial year (estimate) New Zealan d $ $ $ Au st r alia $ $ $ Asia an d t h e Pacif ic Islan d s $ $ $ Un it ed Kin g d o m & Eu r o p e $ $ $ USA/Can ad a $ $ $ Ot h er (sp ecif y ) $ $ $ Total $ $ $
Wh at p er cen t ag e o f y o u r f ee in co m e is p aid t o su b co n t r act o r s o r co n su lt an t s? %
Please p r o v id e d et ails o f t h e f iv e lar g est co n t r act s u n d er t aken d u r in g t h e p ast f iv e y ear s:
Name Description of
contract Duration
Your major
responsibilities Fees earned
(a) $ (b ) $ (c) $ (d ) $ (e) $
Contractual agreements
Do y o u h av e st an d ar d t er m s u p o n w h ich y o u su p p ly y o u r p r o f essio n al ser v ices? Yes No If Yes, p lease at t ach co p ies o f an y liab ilit y exclu sio n clau ses, d isclaim er s o r h o ld h ar m less p r o v isio n s.
Will y o u o r h av e y o u en t er ed in t o co n t r act s w it h h o ld h ar m less p r o v isio n s w h ich p r o v id e t h at y o u w ill in d em n if y t h e o t h er p ar t y ag ain st all claim s o r d em an d s?
Yes No If Yes, p lease p r o v id e d et ails:
Wh en en g ag in g in d ep en d en t co n su lt an t s o r co n t r act o r s, d o y o u en su r e t h at t h o se co n su lt an t s:
(a) Main t ain t h eir o w n p r o f essio n al in d em n it y in su r an c e? Yes No (b ) Ar e b o u n d b y co n t r act t o accep t f u ll r esp o n sib ilit y f o r t h eir o w n act io n s?
Yes No
Insurance history
Hav e y o u ev er h ad an y in su r an ce d eclin ed o r can c elled ; r en ew al r ef u sed ; sp ecial co n d it io n s im p o sed ; excess im p o sed ; o r claim r eject ed ? Yes No
If Yes, p lease p r o v id e d et ails:
Please p r o v id e d et ails o f y o u r cu r r en t p r o f essio n al in d em n it y co v er ag e:
Cu r r en t in su r er : Expiry date:
Claims history
Has an y p ar t n er , p r in cip al, d ir ect o r o r st af f m em b er ev er b een t h e su b ject o f
d iscip lin ar y p r o ceed in g s f o r p r o f essio n al m isco n d u ct ? Yes No If Yes, p lease p r o v id e d et ails:
Hav e an y claim s ev er b een m ad e ag ain st y o u , y o u r p r ed ecesso r s in b u sin ess, o r an y p r esen t o r f o r m er p ar t n er , p r in cip al, d ir ect o r o r em p lo y ee o f t h e b u sin ess?
Yes No If a cu r r en t lo ss su m m ar y is av ailab le f r o m y o u r p r esen t an d p ast in su r er s p lease at t ach a co p y .
If Yes, p lease p r o v id e t h e f o llo w in g d et ails in r esp ect t o each m at t er :
Date matter notified Name of insurer (if any) Brief details of each matter Amount paid or estimate of potential liability Is matter finished or outstanding?
Ar e y o u , o r an y p ar t n er , p r in cip al, d ir ect o r o r em p lo y ee, after enquiry, aw ar e o f an y claim s o r cir cu m st an ces w h ich m ig h t r esu lt in claim s ag ain st y o u o r y o u r p r ed ecesso r s in b u sin ess o r an y p r esen t o r f o r m er p ar t n er , p r in cip al, d ir ect o r o r em p lo y ee o f t h e
b u sin ess? Yes No
If Yes, p lease p r o v id e t h e f o llo w in g d et ails in r esp ect t o each m at t er :
Name of claimant or potential claimant
Brief description of
Cover required
Lim it o f in d em n it y r eq u ir ed : $ $ $ Level o f excess r eq u ir ed : $ $ $ Op t io n al ext en sio n :
Do yo u r eq u ir e co ver f o r p ar t n er s, d ir ect o r s o r p r in cip al’s p r evio us b usin ess? Yes No If Yes, p lease p r o vid e t h e f o llo w in g d et ails in r esp ect o f each p ar t n er , p r in cip al an d d ir ect o r :
Name Names of previous firms Details of any claims made against previous firms
Declaration
On b eh alf o f all p r o p o sed Insur ed ’s I/We d eclar e an d agr ee t h at :
a) all in f o r m at io n p r o vid ed , in t h is p r o p o sal o r at t ach m en t s, is t r ue an d co m p let e in ever y r esp ect an d t h at n o Mat er ial Fact s r em ain u n d isclo sed ;
b ) if t h is r isk is accep t ed , su ch in f o r m at io n w ill b e in co r p o r at ed in t o an d f o r m t h e b asis o f t h e co n t r act o f in su r an ce;
c) I/We u n d er st an d t h at In t er n at io n al Un d er w r it in g Agen cies r eq u ir es t h is in f o r m at io n in o r d er t o evaluat e t h is p r o p o sal an d t h at t h e Pr ivacy Act 1993 en t it les m e/u s t o h ave access t o , an d r eq u est t h e co r r ect io n o f , an y in f o r m at io n r et ain ed ;
d ) In t er n at io n al Un d er w r it in g Ag en cies is au t h o r ised t o d isclo se in f o r m at i o n t o it s ad viser s, r ein su r er s, o t h er in su r er s an d p ar t ies w it h a f in an cial in t er est in t h e sub ject m at t er o f t h is p r o p o sal;
e) In t er n at io n al Un d er w r it in g Ag en cies is au t h o r ised t o ch eck d et ails ag ain st t h e In su r an ce Claim s Reg ist er an d t o p lace in f o r m at io n o n t h e In su r an ce Claim s r eg ist er w h ich o t h er in su r er s can access;
f ) In t er n at io n al Un d er w r it in g Ag en cies is au t h o r ised t o o b t ain f r o m o t h er p ar t ies an y in f o r m at io n w h ich m ay b e r elevan t t o t h e accep t an ce o f t h is r isk;
g ) Th e sig n in g o f t h is p r o p o sal d o es n o t b in d eit h er p ar t y t o co m p let e t h e co n t r act an d t h at n o co ver w ill b e in f o r ce u n t il co n f ir m ed b y In t er n at io n al Un d er w r it in g Agen cies.
In su r ed (s) sig n at ur e:
