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Insurance Brokers
Professional Indemnity Proposal Form

The completion of this form in no way binds the Proposer to purchase insurance, nor does it bind Underwriters to give insurance. Any information given will only be passed to Underwriters for the purpose of quotation and will be treated as confidential.

Name of Company(s) to be insured:* Date Established: *
Contact
Name(s): *
Address:
Postcode: Email: *
Tel: Mobile: *
Fax: Number of Offices:
Website:

2. Details of all Principals, Partners, Directors

Name Age Qualifications
Partner 1:
Partner 2:
Partner 3:
Partner 4:
Total Number of Employees Excluding Above:

3. Please state total gross commission plus fee income:

Last Complete Year Current Year Estimate Current Year
Estimate
Year End
Commission plus fees from UK clients
£
£
£
£
Commission plus fees from overseas
clients (Ex USA/Canada)
£
£
£
£
Commission plus fees from
USA/Canada clients
£
£
£
£
Total commission plus fees
£
£
£
£
Average commission plus fee per
client
£
£
£
£

4. Fee Split

Please give an approximate breakdown of the total commission plus fee income for the last complete financial year

TOTAL
MOTOR – Personal
%
MOTOR – Commercial
%
HOUSEHOLD & OTHER PERSONAL LINES
%
BLOODSTOCK:
%
COMMERCIAL PROPERTY
%
PROFESSIONAL INDEMNITY
%
OTHER COMMERCIAL
%
MARINE /AVIATION – Personal
%
MARINE / AVIATION – Commercial
%
INVESTMENT BUSINESS - As defined by Financial Services Act (1986)
%
LIFE (NON-REGULATED PRODUCTS)
%
BUILDING SOCIETY AGENCY
%
MORTGAGE BROKING
%
REINSURANCE
%
RISK MANAGEMENT
%
LOSS ASSESSING / CLAIMS ADJUSTINGNG
%
OTHER (Please specify)
%
TOTAL
%

5. Please state the two largest sums insured that you place in respect of:

i) Fire and perils (i.e. the material damage and business interruption combined exposure):

Client Risk Sum Insured
£
£

ii) Public liability, products liability or professional indemnity risks:

Client Risk Limit of Indemnity
£
£

iii) Property Owner risks:

Client Risk Sum Insured
£
£

6. Please give details of any insurance placed with insurers or Underwriters who do NOT operate in the United Kingdom or who are not memebers of the ABI or Lloyds.

7. Please give details of any insurance placed, either directly or indirectly, with unrated insurers (an unrated is deemed to mean any insurer who does NOT have a financial strength rating above B with AM Best, Standard and Poor’s and/or any other recognised rating agency)

8. Does the firm(s) operate any Binding Authority arrangement whereby an Insurer or Underwriter
has granted the Firm(s) authority to either quote terms, set rates or handle claims without referral?  

If NO, please go to question 9. If YES, please complete the following

Nature of Binding Authority Class of Business Insurer &
Reference
Maximum
Limits/ Sums
Insured
Est. Total Commission
Income
i) Non-discretionary with no deviation from the Binding Authority in respect of the type of risk, rates, period of insurance or policy wording, as specified in the Binding Authority
ii) Non-discretionary with no deviation from the Binding Authority in respect of the type of risk, period of insurance or policy wording, but with a limited amount of deviation to the extent of specified discounts or loadings
iii) Non-discretionary with no deviation from the Binding Authority in respect of the type of risk and wording applicable but with deviation permissible in respect of the period of insurance or non-specified discounts or loadings
iv) Discretionary Binding Authority with no limits in respect of the type of risk, rating, wording or period of insurance
v) Claims Handling Authority

9. i) Are all the Binding Authorities in written form?  

ii) Do all Binding Authorities have specified renewal date?  

iii) Do all Binding Authorities specify those individuals who have authority to bind risks under the Binding Authority?  

- If NO to question 9, iii), do you restrict those individuals who can bind risks under the Binding Authority to senior staff with a minimum of five years insurance experience?  

iv) Do all Binding Authorities restrict the territorial limits to those risks based within the United Kingdom?  

v) Does the firm(s) delegate the Binding Authority to any other party?  

If NO to any of question 9, please provide an explanation:

10. i) Have any claims or circumstances in respect of the risks to which this form relates ever been notified to insurers or made against the business or any of the Principals, Partners or Directors whether successful or not?  

ii) Are any of the Principals, Partners or Directors, AFTER FULL ENQUIRY, aware of anycircumstance which might give rise to any such claim?  

iii) Has any proposal in respect of the risks to which this form relates ever been declined orhas any such insurance ever been cancelled or renewal refused?  

If YES to any of question 10, please provide an explanation:

11. Other material information

12. i) Does the firm currently hold Professional Indemnity Insurance?  

ii) What limit of Indemnity do you require?  

Name of Current Insurers
Name of your broker
Renewal Date
Limit of indemnity
Premium
Excess

PLEASE READ THESE PARAGRAPHS CAREFULLY BEFORE SIGNING THE DECLARATION:

It is essential that every Proposer or Assured when seeking a quotation to take out or renew any insurance makes a fair presentation of their risk to the prospective insurer.

DUTY TO MAKE A FAIR PRESENTATION

You have a duty to make a fair presentation of the risk to be insured to the insurer. This requires the disclosure of any information which would influence the judgement of a prudent insurer in deciding whether to accept your insurance, impose special terms, or charge an increased premium.

A proposal or any other document relating to the contract of insurance, must be answered fully and accurately. All representations must be substantially correct if relating to matters of fact, or made in good faith if they are matters of expectation or belief. Please do consider the questions regarding “any other information” very carefully in the light of the duty of fair presentation. The provision and documentation of this information is your responsibility.

Please be aware that a failure to make a fair presentation of your risk may affect the payment of your claims, cause additional charges to be made by the insurer, or even invalidate the policy.

You are required to disclose what should “reasonably have been revealed by a reasonable search of information available to you”. Please note that this includes what is in the knowledge of all senior management within your organisation (senior officers not just directors), and what is known to other organisations.

Information must be disclosed in a way which is reasonably clear and accessible to a prudent insurer. This duty arises not only at inception of the policy but also at renewal or in the event of any material change in your risk during the period of insurance.

If you have any doubt as to what constitutes a relevant fact or circumstance please do not hesitate to ask for advice.

DECLARATION

I/we declare that, after full enquiry, the contents of this proposal are true and that I/we have not misstated, omitted or suppressed any material circumstance or information. I/we agree that this proposal together with any other information supplied by me/us shall form our fair presentation of the risk to be insured. If there is any material alteration to the facts and information which I/we have provided or any new material matter arises before the completion of the contract of insurance, I/we undertake to inform Underwriters.
I/we hereby consent to any information I/we have provided being processed by you for the purposes of providing insurance and claims handling, which may necessitate sharing such information with third parties. Smart Sure may use this information for marketing (by post, telephone, e-mail or fax) subject to the conditions of the General Data Protection Regulation (GDPR) 2018. If you do not wish these details to be used for marketing please inform Smart-Sure Limited in writing. Under GDPR you have the right to access or amend the information we hold about you. If you would like to exercise either of these rights please contact Smart-Sure Ltd.

Signature Position within the
Company
Name Date