Firm Details (fields with * are mandatory) Email *  Name Date of establishment Address  *  *  * During the past five years has: The name been changed?  Yes   No If yes, please give full details Has any business been purchased or any merger or consolidation taken place?  Yes   No If yes, please give full details Please supply copies of all standard forms of contract agreement and/or letters of appointment used by the Firm. Supplied Not Supplied Partners Details (Records with empty Partners Names will not be saved.) Names of Partners Qualifications Date Qualified Years Partner at this Firm How long a Partner If there are no formally qualified Partners please supply career histories. Please state the total number of: Partners Self Employed or Contract hired Staff: Qualified Others Is coverage required for the past partners of the Firm, where applicable?  Yes   No If yes, please give full details Firm's Activities Please give a clear description of your Firm's activities and enclose any brochures and/or leaflets issued by the firm. Please categorise the activities described above and indicate the approximate percentage of work this represents. Explain whether this is a percentage of fees, payroll etc. Category Percentage   Gross Income/Fees (delete as applicable) Past Financial year to Current Financial year to Estimate for coming financial year to   Please insert date financial year end Income received from operations involving ROI/UK based locations Income received from operations involving foreign locations Largest single income/fee received from a client   Your 3 largest home based projects    1.   2.   3.  Your 3 largest projects where the "end product" of such work is carried out in a foreign country. Country Period of project Approx. total value of project Gross income received from project Type of project and services provided   Is this Firm or any Partner connected or associated (financially or otherwise) with any other Firm or Organisation?  Yes   No If yes, please give full details Are any major changes in the firms activities planned or anticipated within the next 2 years.  Yes   No If yes, please give full details Sub-Contractors Details Does the Firm engage Sub-Contractors or Consultants  Yes   No If yes, please answer Does the firm require Sub-Contractors or Consultants to carry professional indemnity insurance?  Yes   No If 'YES', for what limits?  What percentage of the Firm's gross income is paid to:    Sub-Contractors?   Consultants?    Is the Firm or any Partner a Consortium member or involved in any work carried out in association with any other organisation? Yes   No If 'YES', please state in what capacity and give the names of other members and their roles in the consortium. Is coverage required for liability arising out of this work? Yes   No N.B. Such work may be subject to special conditions and/or a separate insurance contract. Previous Similar Insurance Details (Records with empty Period will not be saved.) Please give particulars of previous similar insurance Period Limit Excess Insurer Last Years Premium Has any similar insurance for the Firm or any predecessors or present Partners been declined, cancelled or renewal refused? Yes   No If yes, please give full details Has any claim been made against the Firm or any Partner including whilst in a previous Firm? Yes   No If yes, please give full details Are any of the Partners after full enquiry, aware of any circumstances which may give rise to a claim against this Firm or its Partners or its predecessors in business or against any of the former Partners or Employees? Yes   No If yes, please give full details Are you aware after enquiry of any circumstances which might otherwise affect the Company's consideration of the risk? Indemnity Limit Required   £100,000  £250,000  £500,000  £1,000,000  Others please specify  Preferred Self-Insured Excess each Claim  £500 £1,000 £2,500 Others Amounts  Do you require the following extensions? Libel and Slander Yes No Dishonesty of Employees Yes No Loss of Documents Yes No Do you have Computer Records Yes No Fidelity Guarantee for Staff Yes No Breach of Confidentiality Yes No The previous business activities or any Principal Yes No

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