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INSURANCE FOR ARBORICULTURAL AND FORESTRY CONTRACTORS AND CONSULTANTS
PROFESSIONAL INDEMNITY
PROPOSAL FORM
Exeter House, Tylers Court, Cranleigh, Surrey. GU6 8SA. Tel: 01483 274792
Fax: 01483 278326
E-mail: [email protected] Web: www.thecleargroup.com
Authorised and regulated by the Financial Conduct Authority
v2 16/04/2014
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Mac Operating System
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Mac users MUST install Adobe Reader. Mac Preview WILL NOT work with fillable
PDF forms.
1) Install the most recent version of Adobe Reader http://get.adobe.com/reader/
2) Save the form to your local drive on your own computer
3) Note the location of the saved file
4) Using Adobe Reader Open the newly saved blank form
5) Enter all required information
6) Save the form again with your completed information on your local drive
7) The form is now ready to email to us
DO NOT ATTEMPT TO COMPLETE A FILLABLE PDF USING MAC PREVIEW
2 INSTRUCTIONS
1. Please ensure that this Proposal Form is completed in full by either a Partner, Director, Principal or Officer of the Proposer. 2. Please fully complete this Proposal Form. It is very important that the person completing this form understands that full
disclosures must be made on the basis of proper enquiries and that the questions and statements below attach to the Policy if one is issued. The Insurer relies upon the answers provided in this Proposal Form when deciding whether or not to offer insurance to the Proposer, and if so, on what terms.
3. The Proposal Form applies to the “Proposer” which includes all person(s) or businesses applying for insurance. 4. Wherever the word ‘Partner’ appears herein, this is deemed to read ‘Partner (s), Director (s), or Principal’.
5. Wherever the word ‘Employee’ appears herein, this is deemed to read ‘Any person who is or has been under a contract of service for or on behalf of the Firm’.
6. Should the Firm require any advice as what may constitute material information or any information which is relevant to this proposal form then the Firm must seek advice before same is completed.
7. Should there be insufficient space to answer any questions please attach additional pages of information, ensuring that there is clear reference to the question(s) to which it/they refer to on the Proposal Form.
If a supplement attaches to this Proposal Form please tick here THE FIRM
1. Name (including Trading Name if you are a Sole Proprietor or Partnership)
2. a. Main Postal Address (including postcode)
b. All other branch offices (Town/City only)
c. Date Established
d. Telephone Number
e. Mobile Number
f. Email Address
g. Website Address
PARTNER (S) / PRINCIPAL DETAILS
3. Full Name Age Qualifications Date Obtained No. of years
with Firm
AMALGAMATIONS
4. Has the name of the Firm (s) changed or has any amalgamation or takeover occurred?
If YES please provide full details:
YES NO
PARTNERS PREVIOUS LIABILITY (PPL)
5. Is indemnity required in respect of PPL prior to joining the firm?
If YES please provide:
YES NO
a) Name (s) of Individual (s) concerned
b) Name of previous firm (s)
c) Date (s) at which Individual (s) joined and left previous firm (s)
d) How long (in years) a Partner at previous firm (s)
e) How many other Partners at the previous firm (s)
f) Have any claims for alleged Professional Negligence been made and settled against previous firm (s) or are there any outstanding?
If YES please provide full details
EMPLOYEE(S) DETAILS
6. Please provide numbers of: a) Qualified Staff
b) Unqualified Staff
c) Contract hired staff
4 ANNUAL FEE INCOME
7a. Do you carry out the following:
i) Surveys, inspections and/or consulting work in respect of the effect trees and vegetation may have or have had on the structural integrity of property and the possibility of structural movement, subsidence and heave?
YES NO
If YES do you have at least 3 years experience of providing such reports ? YES NO
ii) Tree Hazard Evaluation Reports YES NO
If YES do you have at least 3 years experience of providing such reports ? YES NO iii) If YES to either of the above please state fee income:
iv) If YES have you carried out such work in the past? YES NO
If YES to the above please give details, including dates, in the box below:
7b. State Firm’s annual Gross Fee income for each of the last three financial years and anticipated Gross Fee income for the next financial year:
LAST 3 YEARS Next
Financial Year
20 20 20
TOTAL GROSS FEES
State which month ends the Firm’s financial year:
What percentage of Gross Fee income relates to work in the EU (other than UK)?
Do you work in countries outside the EU? YES NO
If YES please provide full details:
OCCUPATION
8. Is the business of the Firm (s) a part time occupation? If YES please provide full details:
YES NO
MANUAL WORK
9a. Does the Firm also carry out any manual work, e.g. Arboricultural, Forestry, Landscape Gardening and the like?
YES NO
b. Does the Firm ever provide professional advice for which a fee is NOT charged? If YES please state:
YES NO
Last Financial
Year
Current Financial
Year i) Turnover where the Firm provides no professional advice
ii) Turnover where the Firm provides professional advice but does not charge for that advice
iv) Gross Fee income where the Firm does not undertake manual work (This should correspond with the information given in answer to Question 6)
REGISTERED CONSULTANT
10. Is any partner, principal or employee a Registered Consultant of the:
a) Arboricultural Association? YES NO
If YES please state names and Registration Nos:
b) Institute of Chartered Foresters? YES NO
If YES please state names and ICF Membership Nos:
*If insufficient space please continue on page 8 using the ‘other information’ box
6 ASSOCIATED FINANCIAL INTERESTS
11. Please answer the following :
a) Does any Partner of the Firm hold a Partnership/Directorship or have any other financial interest in any other Firm, Company or Organisation (other than as share or stockholders in a Publicly Quoted Company)?
YES NO
b) Is there any person above who has a controlling interest in any of the organisations referred to in Question 11.a)?
YES NO
c) Does the Firm carry out any work for any of the organisations referred to in Question 11.a)?
YES NO
If YES to 11a), b) or c) please provide full details:
FORMS OF CONTRACT
12. Does the Firm use a standard form of contract, agreement of letter of engagement?
If YES please attach a copy
YES NO
SUB-CONSULTANT(S)
13. Does the Firm pass work to any sub-consultant (s)?
If YES please provide full details of the sub-consultant (s) and their Professional Indemnity insurance:
YES NO
PLEASE NOTE: Underwriters legal rights of subrogation against such sub-consultant (s) will remain unless specifically requested and waived by Underwriters.
CLAIMS AND/OR RELATED MATTERS
14. Please give very careful consideration to the following five questions. It is absolutely essential that these questions are answered correctly, failure to do so could well prejudice the Firm’s rights under any insurance contract effective with Underwriters.
a) Have any claims for professional negligence, during the last six years, been made against the Firm or any current or former Partner whilst acting on behalf of the Firm?
If ‘YES’ please provide full details, including amounts involved:
YES NO
b) AFTER FULL ENQUIRY within the Firm are there any circumstances, allegations or incidents which could give rise to a claim against the Firm?
YES NO
If ‘YES’ please provide full details even if the Firm believes that their actions have been beyond reproach:
c) Has any current or former Partner or Employee ever been asked to stand before or attend a Disciplinary Committee or Regulatory Board, other than as a witness or independent expert?
YES NO
d) Has any current or former Partner or Employee ever been declared bankrupt, insolvent or entered into any special financial arrangement with creditors.
YES NO
e) Has any current or former Partner or Employee ever been convicted of a Criminal Act, other than motoring offences?
If ‘YES’ please provide full details:
YES NO
WORKING RECORDS/ARCHIVED FILES
15. Please answer the following :
a) Are all working papers, records or documents relating to the business activities of the Firm (or any predecessors in business as stated in answer to question 4 or 5) kept for at least 6 years in a secure and accessible location?
If NO why not?
YES NO
b) Have any working papers, records or documents relating to the business activities of the Firm been destroyed (which have not been duplicated or stored on micro file/computer disk)?
YES NO
CURRENT PROFESSIONAL INDEMNITY POLICY
16. Please State particulars of the Firms current insurance:
Level of Indemnity Uninsured Excess Premium Insurer (not Broker) Renewal Date
£ £ £ £
Current Policy Retro-Active Date
QUOTATIONS REQUIRED
17a. Please tick which box applies:
i) £250,000 ii) £500,000 iii) £1,000,000 iv) £2,000,000
8 v) Other (specify)
b. Do You Require a quotation for Public Liability Insurance? YES NO
If YES do you ever carry out Roped Access Work? YES NO
PREVIOUS PROFESSIONAL INDEMNITY INSURANCE
18. Has any Insurer ever cancelled, declined, refused to renew or required an increased premium or imposed special (punitive) policy terms?
If YES please provide full details:
YES NO
If there is any other information you need to disclose to Underwriters as part of your Application please insert this in the box below, continuing on a separate sheet if necessary:
IMPORTANT NOTE
Similar to other professional insurances Professional Indemnity policies are underwritten on what is known as a ‘claims made basis.’ This means that the policy will provide cover against those claims or circumstances that are discovered and notified to the Insurer during the period of insurance. The nature and type of insurance cover offered can vary from policy to policy and insurer to insurer. It is therefore
£
important the Proposer ensures the cover meets its needs and if in any doubt seeks professional advice from Clear Insurance Management Ltd.
DATA PROTECTION
By signing this Proposal Form the Proposer consents to the Insurer or its representatives using the information the Insurer may hold about the Proposer for the purpose of providing insurance and handling claims and to process sensitive personal data about the Proposer where this is necessary in compliance with the provisions of the Data Protection Act 1998. This may necessitate providing such information to third parties.
MATERIAL FACTS
All material facts must be disclosed, including any which might be expected to arise or change prior to the inception date of the contract of insurance. Failure to do so may cause the contract of insurance to be void. A material fact is one likely to influence the acceptance of assessment of risk by the Insurer. If the Proposer is in any doubt as to what constitutes a material fact they should consult their insurance broker.
DECLARATION
I/We declare that the above statements and particulars, together with any other information supplied/attaching to this Proposal Form are true and I/We have not suppressed or misstated any material facts. I/We agree that this declaration shall be the basis of the contract between the Firm and Underwriters, I/We undertake to inform
Underwriters of any material alteration to these facts occurring before/during currency of the Contract of Insurance. Please tick to declare that the details given on this form are true and complete and to the best of your knowledge
Signed
Dated
Position
PLEASE TICK IF YOU WOULD LIKE INFORMATION ON ANY OF THE FOLLOWING INSURANCES:
Arbortruck Commercial Vehicle Contractors Plant & Equipment Hired-In Plant
Personal Accident (and optional illness) Legal Expenses
Directors and Officers Liability Buildings and Contents Other (please describe)
