Welcome to Emsons Professional Indemnity Quotation Form
 
Please note this form is for submitting details of your insurance risk to us. It does not in turn provide you with any automatic quotation or any cover.

Any quotation that we subsequently offer on the basis of information that you have supplied will be confirmed to you by post or telephone. NO COVER will be in force unless we notify you.

We may require additional information from you in order to prepare a quotation in which case you will be notified in writing, by email or post.

Any quotation request you have submitted will be verified with you prior to any contract coming into force.

Please complete the sections as directed
There is a submit button at the end of the form to mail it to us.
You will automatically be sent a copy of the form by e-mail, but if you wish to print before sending, please press CTRL + P before submitting the form
The information you supply may form the basis of any policy subsequently quoted, it is important that the information is both correct and as comprehensive as possible.
Wherever you see this means that there is further information to view from our technical archive.


Any quotation submitted to Emsons will be verified with the Client before any cover is granted or any liability to pay any premium is incurred.

Any policy that this quotation form may apply to is written under UK Jurisdiction.

 
Section 1 - General Details
 
Name of firm, company or individual
Head Office Address
 
Please advise if you have other offices YesNo
 
Date when first established
 
Section 2 - Staff Information
 
Director / Partner / Principle 1
Name
Qualifications / Year Obtained / How long a Director/Partner/Principle of this firm or company
 
Director / Partner / Principle 2
Name
Qualifications / Year Obtained / How long a Director/Partner/Principle of this firm or company
 
Director / Partner / Principle 3
Name
Qualifications / Year Obtained / How long a Director/Partner/Principle of this firm or company
 
Director / Partner / Principle 4
Name
Qualifications / Year Obtained / How long a Director/Partner/Principle of this firm or company
 
Director / Partner / Principle 5
Name
Qualifications / Year Obtained / How long a Director/Partner/Principle of this firm or company
 
Director / Partner / Principle 6
Name
Qualifications / Year Obtained / How long a Director/Partner/Principle of this firm or company
 
WE MAY REQUIRE CV'S IN SOME CASES - WE WILL ADVISE YOU ACCORDINGLY
Are you connected or associated (financially or otherwise) with any firm, company or organisation? YesNo
If YES, please give details:
 
Please give total numbers of:
Partners/directors/principles
Qualified Staff
Other Staff (ex admin)
Administrative Staff (typists etc.)
Contract hired staff
Please provide a full description of all your activities:
 
Please categorise the activities outlined above, and indicate the approximate percentage of the gross income/fees each one represents
 
Do you anticipate any major changes in these activities in the forthcoming 12 months? YesNo
If YES, please supply full details:
 
Are you involved in any process of manufacture, construction, alteration, repair, installation or sale or supply of products, other than a pure consultancy capacity as described above? YesNo
If YES, please supply full details:
 
 
Section 3 - Financial Information
 
Please give the amount of gross income/fees for the last 3 financial years, and also an estimate for the current financial year:
Year
U.K.
Overseas excluding U.S.A/Canada
U.S.A / Canada
Year
U.K.
Overseas excluding U.S.A/Canada
U.S.A / Canada
Year
U.K.
Overseas excluding U.S.A/Canada
U.S.A / Canada
Current Year
U.K.
Overseas excluding U.S.A/Canada
U.S.A / Canada
Please give date of your financial year end
Please provide the following information relating to the 3 largest projects you have been involved with during the last 12 months
Project 1
Description
Country of work
Client's name
Contract value
Date contract commenced
Date contract finished
Project 2
Description
Country of work
Client's name
Contract value
Date contract commenced
Date contract finished
Project 3
Description
Country of work
Client's name
Contract value
Date contract commenced
Date contract finished
Do you work other than from your U.K. offices? YesNo
 
Do you accept liability other than under the jurisdiction of the U.K courts? YesNo
 
If you have answered YES to either of the previous two questions please give full details (i.e. list the jurisdictions and amount of work therefrom etc.)
 
Do you use a standard form of contract, agreement or letter of appointment? YesNo
 
If YES please enclose a copy as an attached file or fax on 01883 621430
Is any work put to sub-contractors? YesNo
If YES please give full details
 
Do you require sub-contractors to carry insurance and for what limits? YesNo
If YES please give full details
 
What percentage of your fees are paid to sub-contractors?
(NOTE: Underwriters retain rights of recourse against sub-contractors unless specifically agreed otherwise)
Have you previously been insured or are you currently insured? YesNo
 
If YES please give the following details:
Name of insurer
Indemnity Limit
Excess
Premium
Date of expiry
Do you require any alteration to the indemnity limit or excess level? YesNo
If YES, please give details
 
Have any claims alleging negligent act, error or omission (successful or otherwise) been made against you, your predecessors in business, or any present or past partners, principal or directors? YesNo
If YES, have such matters been notified to current or previous insurers?
Are you or any of the partners, directors or principles, after having made enquiry of all appropriate staff, aware of any of the following matters?
Any circumstances which may give rise to a claim against you, your predecessors in business, or any past or present partner? YesNo
 
The receipt of any complaints, whether oral or in writing, regarding services performed or advice given by you? YesNo
 
(If yes, We may ask you for separate and specific details)
Should we contact yourself to obtain this information? YesNo
 
Have you at any time been refused similar insurance, or quoted increased premiums or had special terms imposed? YesNo
If YES, please give full details
 
Do you require any of the following extensions?
Libel & Slander YesNo
 
Dishonesty of Employees YesNo
 
Loss of Documents YesNo
 
Unintentional Breach of Copyright YesNo
 
Unintentional Breach of Confidentiality YesNo
 
If any of the above extensions are required, are you aware of any past or current claims, or circumstances which may lead to a claim in respect of any extension requested, whether insured or not? YesNo
If YES, please give full details
 
 
Section - Decleration
 
I/We declare that the statements and particulars in this proposal are true and that I/We have not mis-stated or suppressed any material facts.
. I/We agree that this proposal, together with any information supplied by me/us shall form the basis of any contract of insurance effected thereon.
I/We undertake to inform insurers of any material alterations to these facts occurring before/during/after completion of the contract of insurance.
Dated
FOR AND ON BEHALF OF
Name of Partner, Director or Principal
The completion of this proposal does not bind the Proposers or Underwriters to complete a contract of insurance
You will be forwarded a copy of this form by e-mail. Please enter your address below
E-mail address
 
IMPORTANT : You must have read and accepted the terms and conditions of the Declaration that accompanies this proposal - click here to view the terms - CLICK
 
Have you read and understood the terms of the Declaration? Yes No
 
IMPORTANT : You must have read and accepted the terms and conditions of the Data Protection clause that accompanies this proposal - click here to view the terms - CLICK
 
 
Have you read and understood the terms of the Declaration? Yes No
 

 
Upon receipt of your e-mail a response will be given within 1 working day at the most.