HOULDER INSURANCE SERVICES PROFESSIONAL INDEMNITY PROPOSAL FORM INFORMATION TECHNOLOGY INDUSTRY

Section 504 provides for equal opportunity to enter facilities and participate in programs and activities. It does not require that every facility or program be accessible.

Please specify expenses related to the trip cancellation - if insufficient space please attach separate sheet. Have you received any compensation from a travel agency,

Give details of any previous claim made for any previous injury against any insurance company: (please attach separate sheet if insufficient) Payee.. Please tick preferred method

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

2.2(ii) Pensions within 2.2(i) transferring rights from a Non Statutory Occupational Pension Scheme to a Personal Pension Plan. 2.3 Transfer of rights in a Non Statutory

Do carry out work only under a standard contract signed by every client? Yes No PLEASE SUPPLY A COPY OF YOUR STANDARD FORM OF CONTRACT, IF RELEVANT, OR OTHERWISE A

If there is insufficient space to answer questions, please use an additional sheet and attach it to this form (please indicate section number).. Please complete this Proposal form

(Please print or type. If space is insufficient, please attach a list to this Letter of Transmittal in the above form.) It is understood that, upon receipt of this Letter