John Ansell & Partners Limited

Insurance Brokers
Overseas House
19/23 Ironmonger Row
LONDON
EC1V 3QN
Telephone Number 020 7251 6821
Fax Number 020 7490 0708
email:- enquiries@ansell.co.uk

PROPOSAL FORM

PROFESSIONAL INDEMNITY INSURANCE

I.T.

COMMUNICATIONS

AND

COMPUTER CONSULTANTS

 
I.T.
COMMUNICATIONS
AND
COMPUTER CONSULTANTS
PROFESSIONAL INDEMNITY INSURANCE

This proposal form must be completed in ink by a Partner, Principal or Director of the Firm or Company. All questions must be answered to enable a quotation to be given. The completion and signature of this proposal does not bind the Proposer or Underwriters to complete a Contract of Insurance.

If there is insufficient space to answer questions, please continue on your headed notepaper and attach it to this form.

Please provide a brochure, if possible, and any standard contract terms, conditions, agreements or letters of appointment which you have with your clients.

PLEASE TYPE OR CLEARLY PRINT YOUR ANSWERS TO ASSIST THE UNDERWRITERS' CONSIDERATION OF THE PROPOSAL
_____________________________________________________
 
1a) Name of Individual or Firm(s) and date established, (including subsidiary Firms requiring cover):

1b) Address(es) of the Proposer (specifying which Partner/Principal/Director is responsible at each location):

1c) Name(s) of any Previous Firm(s) requiring cover and the date(s) on which trading ceased:

  _____________________________________________________
 

2a)
Name of all Partners,
Principals, Directors		 Age and
Qualifications		 Date Qualified Years of practical
expertise in the
Computer Industry

If less than 5 years experience in this occupation, give details of previous occupations.

 
 

2b)
Name of all
Consultants		 Age and
Qualifications		 Date Qualified No.of years in
this capacity
(at this Firm)

If less than 5 years experience in this occupation, give details of previous occupations

2c) Please list those past Partners, Principals or Directors of the Firm for whom cover is required.

  _____________________________________________________
 
3a) Is the Firm admitted to membership of any Association? If YES, please give details.

3b) Has any person in the Firm been subject to disciplinary proceedings by any Professional body? If YES, please give details.

  _____________________________________________________
 
  Please state the total number of:-
 
4a) Partners, Principals or Directors
4b) Software Designers or Systems Analysts
4c) Quality Assurance Staff
4d) Computer Equipment Operators or Data Handling Staff
4e) Hardware or Software Sales Staff
4f) Administrative and All Other Staff
 
  TOTAL:
  _____________________________________________________
 
 
 
  Are you a Sole Practitioner? If so,
 
5a) Is this a part-time occupation? If YES, give brief details of your present full time occupation.

5b) What arrangements have you made for the running of the Firm in the event of sickness or holidays?

  _____________________________________________________
 
6a) Have any major changes in the Proposer's activities/structure taken place in the past twelve months? If YES, please give full details.

6b) Are any major changes in the Proposer's activities/structure/fee growth expected in the next twelve months? If YES, please give details.

6c) Is cover required for any previous activity, now ceased, which is different from that declared within the Proposal Form? If YES, please give details.

  _____________________________________________________
 
7) Please provide a full and clear description of typical projects or assignments of the Proposer undertaken during the past three years.

  _____________________________________________________
 
 
 
8) Please list the activities declared and state the approximate percentage of work carried out in each instance:
 
  General Consultancy

System and/or programme design

Data processing and/or communications

Sales of software packages where the programme
code is modified for a specific client

Sales of software packages which have the
same programme code

Sales of hardware

Other (please specify)

%

%

%

 
%

 
%

%

%
________
100%

  _____________________________________________________
 
 
9) Please state the gross income/fees received for each of the last three financial years and an estimate for the next financial year in respect of income/fees billed to clients based in the following territories:
 
 
 

Year

20

20

20

Next


 

UK
Overseas
excluding
USA/Canada
 

USA/Canada

   
FINANCIAL YEAR ENDING (MONTH/DAY):
  _____________________________________________________
 
 
 
10) Please provide a breakdown of your clients:
  Governmental (including local authorities)

Financial/Statistical

Commercial

Industrial

Technical/Scientific

Medical

Aircraft and ground support equipment expert systems

Pollution control equipment

 %

%

%

%

%

%

%

%
________
100%

  _____________________________________________________
 
 
11a) Please list the Proposer's three largest contracts in the last three years:
 
   
 

i)

ii)

iii)

 
Type of service
and Country
 
Fee
 
Value
Date
Commenced
Date
Finished
11b) What is the largest annual income/fee earned from a single client in the last twelve months?

11c) What proportion of your income is derived from the application of computers in industrial processes or engineering or architectural design other than accountancy, production or stock control?

  _____________________________________________________
 
 
12a) Is the computer and ancillary equipment owned, leased or rented by the Proposer and installed on your own premises and at all times under the care, custody and control of your staff? If NO, please give details.

12b) Do you have access to standby equipment following breakdown or failure or damage to computers or ancillary equipment used by the Proposer? If YES, state what arrangements are made.

12c) Do you ensure that duplicate computer systems records are maintained by yourselves or your clients and kept separately from the original records? If YES, state what arrangements are made.

  _____________________________________________________
 
13) Do you require cover for loss of computer systems records?
  _____________________________________________________
 
  Do you or do you intend to undertake specific contractual liabilities which go beyond the provisions or use of reasonable skill and care? If YES, please:
 
14a) state the proportion of income applicable

 

14b) provide a copy of each form of contract or document

 

14c) give details of any other circumstances by which such liability may be undertaken

 

  _____________________________________________________
 
  Is the Individual, Firm or any Partner, Principal or Director a member of a consortium or joint venture? If YES, please give:
 
15a) name of consortium

 

15b) type of services being provided

 

  _____________________________________________________
 
 
ASSOCIATED COMPANIES QUESTIONNAIRE SECTION

1) Does the Proposer undertake work for any Partnership, Company or Organisation in which he/she or any Partner, Principal, Director or Employee holds a position whereby he/she is able to make major decisions on behalf of such Partnership, Company or Organisation?    YES / NO

If YES please give details:-

2) Is the Individual, Firm or any Partner, Principal or Director connected or associated (financially or otherwise) with any other Practice, Company or Organisation?    YES / NO

If YES please give details:-

3) Has the Proposer or any Partner, Principal or Director been a Partner, Principal or Director or been associated with any business which has ceased trading either voluntarily or compulsorily?    YES / NO

If YES please give details:-

4) Has any Partner, Principal or Director been made personally bankrupt?    YES / NO

If YES please give details:-

5) What percentage of income is derived from Associated Companies as detailed above?

 

6) Is cover required for the work for Associated Companies? (Cover is restricted to claims made by independent Third Parties)    YES / NO

 

7) What percentage of the Proposer's income is paid to sub-contractors?

 

8) Please give details of the work undertaken by sub-contractors:

9) Do you require cover for sub-contractors?    YES / NO

 
PROFESSIONAL INDEMNITY INSURANCE ARRANGEMENTS

Is the Proposer currently insured or been insured previously for Professional Indemnity?

If YES please give the following details:-
 

1a) Name of Insurers
 
1b) Indemnity Limit (State whether Aggregate or Any One Claim)
 
1c) Excess
 
1d) Date of expiry of coverage
 
1e) Number of consecutive years that the Proposer has been insured
 
1f) Premium
  _____________________________________________________
 
  Has any Insurer ever:-
 
2a) Declined to offer Insurance for the Proposer or any Partner, Principal or Director?
 
2b) Imposed any special terms for the Proposer or any Partner, Principal or Director?
 
2c) Cancelled or voided an Insurance for the Proposer or any Partner, Principal or Director?
 
  If YES to any of the above please give details.

  _____________________________________________________
 
3a) What Limit of Indemnity is now required?

£100,000 / £250,000 / £500,000 / £1,000,000 / OTHER - PLEASE STATE
 

3b) What self insured excess (each and every claim) is the proposer prepared to carry?
  _____________________________________________________
 
4a) Does the Proposer always obtain satisfactory written references when engaging senior employees?

YES / NO
 

4b) Is any Partner, Principal, Director or Employee allowed to sign cheques on his/her signature alone?

YES / NO

If YES please describe circumstances and cheque limit:-

 
4c)
Are Employees who receive cash/cheques in the course of their duties required to pay in daily?

YES / NO

If NO please give details:-

4d) How often are checks carried out on all entries in the Cash Book with all paying in books, receipts, counterfoils and vouchers being reconciled with Bank Statements, including the balance of cash and unpresented cheques, independently of Employees receiving or banking monies belonging to the Proposer as well as in trust on behalf of others?

WEEKLY / MONTHLY / QUARTERLY / OTHER

  _____________________________________________________
 
 
 
CLAIMS - PLEASE NOTE IT IS IMPERATIVE TO ANSWER THESE QUESTIONS CORRECTLY - FAILURE TO DO SO COULD PREJUDICE YOUR RIGHTS - IF SPACE IS INSUFFICIENT PLEASE CONTINUE ON YOUR OWN HEADED PAPER TO GIVE FULL DETAILS
 
  FIDELITY:-
 
1a) Has the Proposer sustained any loss through the fraud or dishonesty of any person?

YES / NO
 

1b) Does the Proposer know of any fraud or dishonesty at any time of any past or present Partner, Principal, Director or Employee?

YES / NO

If YES to either of the above, please give full details and state the steps taken to prevent recurrence.

  _____________________________________________________
 
  PROFESSIONAL INDEMNITY:-
 
2a) Has any claim, whether successful or not, ever been made against the Proposer or its predecessors in business or any past or present Partner, Principal, Director or Employee?

YES / NO

If YES a full answer should be given including dates, amounts involved, brief details of the nature of the claim and whether the claim is paid or still outstanding.

2b) Are you or any of the Partners, Principals, Directors or Employees AFTER FULL ENQUIRY, aware of any circumstances which may give rise to a claim against the Proposer, its predecessors in business or any past or present Partner, Principal, Director or Employee?

YES / NO

If YES a full answer as in a) above should be given.

 
IMPORTANT NOTICE CONCERNING DISCLOSURE

It is your duty to disclose all material facts to Underwriters. A material fact is one which may influence an Underwriter's judgement in the consideration of your proposal. If your proposal is a renewal, it is likely that any change in facts previously advised to Underwriters will be material and such changes should be highlighted. If you are in any doubt as to whether a fact is material you should disclose it.

FAILURE TO DISCLOSE could prejudice your rights to recover in the event of a claim or allow Underwriters to void the policy.

I / we declare that the statements and particulars contained in the 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 other information supplied by me/us shall form the basis of any contract of insurance effected thereon. I / we undertake to inform Underwriters of any material alteration to these facts occurring before completion of the contract of insurance.

Dated _______________ day of __________________ 20___

Signature of Partner, Principal or Director

A COPY OF THIS PROPOSAL SHOULD BE RETAINED BY YOU FOR YOUR OWN RECORDS

 
This form should be printed, completed, signed and returned to John Ansell & Partners Limited at the address given on the first printed page.