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Name & Address Details

Employee Details

Please give details of numbers of staff:

Cover

Please provide your current insurance details:

What is limit of indemnity is required

Renewal Date

What excess is required

What does your employer's liability insurance required

Claim and Circumtances

Have any professional indemnity claims, whether successful or not, ever been made against the firm, predecessors of the firm or any of the partners, principals or directors of the firm? If “Yes” please provide full details.
After full enquiry, are any partners, principals or directors of the firm aware of any circumstance which might give rise to a claim? If “Yes” please provide full details.
Yes No
Has any Partner/Director/Member of Employee, either past or present, ever been the subject of disciplinary proceedings by a professional body, association or regulatory body? If “Yes” please provide full details.
Yes No
Has anby Principal ever been convicted of a criminal offence or are any changes pending?(excluding minor motoring offences) If “Yes” please provide full details.
Yes No

Declaration

We declare that to the best of our knowledge and belief, the particulars and statements given in this application are accurate and complete. We declare that we have disclosed accurately every material circumstance which is known or ought to be known by senior management, or those responsible for arranging insurance, following a reasonable search. We understand that failure to disclose a material circumstance may entitle an insurer to impose different terms on our cover or proportionately reduce the amount of any claim payable. In some circumstances an insurer will be entitled to avoid the policy from inception and in this event any claims under the policy would not be paid. We accept that if we are in any doubt about whether a circumstance is material it should be disclosed. We agree that we have a continuing obligation to notify insurers of any material circumstances for the duration of the policy. We accept that deliberate or reckless breach of our duty of fair presentation may be referred to the relevant regulatory bodies.