Professional Indemnity Insurance Proposal Form
IMPORTANT:
This proposal for insurance will be the basis of any
subsequent insurance policy that we issue to you. It is essential that you
answer fully and accurately
all the questions contained in this proposal,
and that you provide us with any and all additional information relevant to the risk to be insured for our decision as to the acceptance of the risk or the terms
upon which it should be accepted. You
failure to comply with this
obligation now may result in the rejection of your claim and the avoidance of
your policy when a claim is made. If
you are in any doubt about the
information to be given, please seek the advice and guidance of your insurance adviser or Pt Pasopati Insurance Broker. If there is insufficient space in this proposal form for you to
provide relevant information, whether as requested or otherwise, please attach
a separate sheet to this proposal form and
return it to us.
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1 |
Name of Firm |
Roy Varghese and Associates |
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2 |
Correspondence address of office |
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3 |
Address
of all other offices |
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4 |
State nature of
the profession / business including full details
of activities undertaken and any intended change in these |
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5 |
When was Firm established |
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6 |
Give details of partners/directors/sole practitioner |
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Name |
Qualifications |
Date
Qualified |
Number of years in this capacity with Proposer |
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7 |
State number of permanent staff |
Technical Staff Non-Technical Staff |
: : |
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8 |
Does the proposer or any
partner / director act on behalf of or undertake for work for any company or business a)
which forms
part of the
same group of
companies or businesses as the Proposer (e.g. subsidiary, associate, parent) Yes or b)
in which
the Proposer or any partner
/ director has
a financial interest and is able to take or influence major
policy decisions in
such Yes If
‘Yes’ in either case, please give details |
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9 |
State the dates of the financial year |
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10 |
State the gross
fees for the last and current financial year (including those paid to
sub-contractors) payable by clients. If the business is newly established, state the estimated gross fees for the forthcoming year. For any non-fee earning business / practice,
state total turnover. Current Financial Year Last Financial Year (Estimate) i)
In territory where domiciled ii)
Elsewhere Total |
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11 |
Is the
Proposer represented in any way Yes If ‘Yes’, state how (e.g. by
subsidiary company, local office, local representative or by any other person or concern holding a power of attorney on behalf of the Proposer) |
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12 |
Current Financial Year State Last
Financial Year (Estimate) a) gross fees paid to sub-contractors b) largest fee earned from any client |
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13 |
Does the Proposer currently
hold any Professional Indemnity Insurance? |
Yes |
No |
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If ‘Yes’ state |
Renewal Date Limit
of Indemnity Retroactive Date |
: : : |
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14 |
a) Is cover required for Partners’ Previous Business? If ‘Yes’, state |
Yes |
No |
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Name
of Partner |
Title
of Previous Business |
Dates
with Previous Business |
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b) Please
indicate if the following covers are
required |
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i) Loss of Documents If ‘Yes’, does the Proposer keep documents in
fire proof cabinets? ii) Libel and Slander iii) Dishonesty of Employees |
Yes Yes |
No No |
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15 |
Has any insurer
in respect of the risks
to which this proposal relates ever |
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a)
declined a proposal, refused
renewal or terminated an insurance? b)
required an increased premium
or imposed special conditions? If ‘Yes’ in either case, please give
details |
Yes |
No |
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16 |
a)
Has any claim been made against
the Proposer or any partner, director, consultant or employee for neglect, error or
omission in relation to professional
duties? b) Has the Proposer or any partner, director, consultant or employee incurred any other loss or expense
which might be within the
terms of the cover?' |
Yes Yes |
No No |
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If ‘Yes’ in either
case, please give details separately of the circumstances of each incident including any amounts paid and the estimated potential cost of the incident. |
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17 |
Is the Proposer of any principal, consultant or employee, after enquiry, aware
of any circumstances which might |
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a)
give rise to a claim
against the Proposer or his predecessors in business or any of the present or
former partners or principals? b)
result
in the Proposer or his predecessors in business or any of the present
or former partners or principals incurring any losses
or expenses which might be within
the terms of the cover? c)
otherwise
affect the Insurer’s consideration of this insurance? |
Yes Yes Yes |
No No No |
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If ‘Yes’,
please give details separately |
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18 |
What is the amount of Indemnity required? Please state
any alternative amounts for which a quotation is required' |
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19 |
Please state the amount
the Proposer wish to contribute towards each and
every claim Please state any alternative amounts for which
a quotation is required |
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Declaration
I/We warrant that
the above statements made by me/us or on my/our behalf are true and complete
and I/We agree that this proposal
shall be the basis of the contract
between me/us and the Company.
I/We agree to accept
a policy in the Company’s usual form for this class of insurance.
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Signature
of Partner / Director |
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Company Stamp |
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Date |
Note – Signing this form does not bind the Proposer
to complete the insurance.
The following is the copy of section 41 of the Insurance
Act 1938
PROHIBITION OF REBATES
1.
No person shall allow or offer to allow either directly as an inducement to any person to take out or renew or continue an insurance in respect of any kind of risk relating to lives or property in India any rebate of the whole or part of the commission payable
or any rebate of the premium shown in the policy nor shall any person taking out or renewing or continuing a policy except
such rebates as may be
allowed in accordance with the published prospectus or tables of the insurer.
2.
Any person making default in complying with the provision
of this section shall be punishable with a fine, which may extend to million
Rupiah.
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