Name: (required)

Email: (required)

Contact Telephone: (required)

Address:

Business Description:

Date Established:

Turnover: Design & Installation: Production Only:

Clerical Salaries:

Use of Heat On-Site:  Yes No

Manual Wages: Own Premises: At Site

Payments to Bona-Fide Subs:

Maximum Work at Height (in metres):

Maximum Work at Depth (in metres):


Directors / Principles Information 1



Name of Directors / Principles

Qualifications

Date Qualified

Duration of Employment in Company


Directors / Principles Information 2



Name of Directors / Principles

Qualifications

Date Qualified

Duration of Employment in Company


Directors / Principles Information 3



Name of Directors / Principles

Qualifications

Date Qualified

Duration of Employment in Company


Directors / Principles Information 4



Name of Directors / Principles

Qualifications

Date Qualified

Duration of Employment in Company


Total Number of Qualified Staff Involved in Design:
Is All Design Done In-House:  Yes No

If outside consultants are used, is it a requirement that they maintain their own Professional Indemnity Insurance? :  Yes No


Please list the details of the 5 largest Contracts in the last 5 years:

Largest Contract 1



Start Date

Completion Date (Approx)

Firm's Contract Value

Total Contract Value

Description of Services


Largest Contract 2



Start Date

Completion Date (Approx)

Firm's Contract Value

Total Contract Value

Description of Services


Largest Contract 3



Start Date

Completion Date (Approx)

Firm's Contract Value

Total Contract Value

Description of Services


Largest Contract 4



Start Date

Completion Date (Approx)

Firm's Contract Value

Total Contract Value

Description of Services


Largest Contract 1



Start Date

Completion Date (Approx)

Firm's Contract Value

Total Contract Value

Description of Services


Please provide an approximate percentage split for the following type of work:-

Home Building



Design Only %

Design & Install %

Installation Only


Public / Commercial Building



Design Only %

Design & Install %

Installation Only


Public / Commercial Building



Design Only %

Design & Install %

Installation Only

Limit of Liability Required:

Public Liability:

Employers Liability:

Professional Indemnity:

Average Contract Value:


In respect of ANY of the risks to which this proposal relates has any claim been made (whether successful or not) against the Firm or any past or present Principal?


 Yes No

If YES, please give details:-

Claim 1



Date of Claim / Loss

Brief Details of each Loss

Cost of Claim / Loss

Estimated cost of Claim / Loss Outstanding


Claim 2



Date of Claim / Loss

Brief Details of each Loss

Cost of Claim / Loss

Estimated cost of Claim / Loss Outstanding


Claim 3



Date of Claim / Loss

Brief Details of each Loss

Cost of Claim / Loss

Estimated cost of Claim / Loss Outstanding


Claim 4



Date of Claim / Loss

Brief Details of each Loss

Cost of Claim / Loss

Estimated cost of Claim / Loss Outstanding


Is any Principal, AFTER FULL ENQURIY, aware of:-

(i) any circumstance which might give rise to a claim against the Firm, any predecessor or any past or present Principal?  Yes No

(ii) any circumstance which might cause any loss to the Firm, any predecessor or any past or present Principle?  Yes No

(iii) any matter which might otherwise affect the consideration of this proposal for insurance?  Yes No

If YES, to any of the above, please give details:-

Declaration

I/We declare that after full enquiry, the contents of this questionnaire are true and that I/We have not misstated, omitted or suppressed any material fact or information..  checked

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