1. Please answer all questions leaving no blank spaces.
2. If you have insufficient space to complete any of your answers, please continue on your headed paper.
3. This form must be signed and dated by a partner, principle or identified officer of the firm.
4. If you have a brochure about your firm’s operations(s), please forward it with the application.

1. NAME OF FIRM: ……………………………………………………………………….
2. ADDRESS OF FIRM: If more than one, please give each address and indicate Partner or Principle who is responsible for work at each address: …………………………………….

…………………………………………………………………………………………………..

3. WHEN WAS THE FIRM ESTABLISHED?
4. DURING THE PAST FIVE YEARS HAS THE NAME OF THE FIRM BEEN CHANGED OR HAS ANY MERGER OR CONSOLIDATION TAKEN PLACE?

Yes No (Please Tick)

If "Yes", Please give full details:

5. PLEASE GIVE THE FOLLOWING DETAILS:

NAME OF ALL PARTNERS/PRINCIPALS	QUALIFICATIONS	DATE QUALIFIED	HOW LONG AS PARTNER/PRINCIPAL OF THIS FIRM	HOW LONG A PARTNER/PRINCIPAL

 

 

6. PLEASE GIVE TOTAL NUMBER OF PRINCIPALS, PARTNERS AND STAFF:

1. Partners or Principals ……….. g) Administrative ………..
2. Other Qualified Accountants ……….. h) Clerical ………..
3. Partly Qualified Accountants ……….. i) Typist, Office Boys ………..
4. Technical Accountants (CAT) ……….. h) Others ………..
5. Trainee Staff ………..

(Please specify) ………..

6. Other Qualified Staff ………..

----------- -----------

TOTAL TECHNICAL ……….. TOTAL NON-TECHNICAL ……….. ======= =======

1. PREVIOUS COVERAGE

Please give particulars of previous similar insurance contracted during the past two (2) years:

PERIOD INSURER LIMITS EXCESS

 

 

 

 

Has any Proposal for similar Insurance made on behalf of the Firm, any predecessors in business, or present Partners or Principals, ever been declined or has any such Insurance ever been cancelled or renewal refused?

Yes No (please tick)

If ‘Yes’, please give full details: ………………………………………………………..

……………………………………………………………………………………………

2. (1) Please indicate the annual professional fees for past financial year ending:

………………………………………………………………………………….

(2) Estimate for coming financial year ending: ……………………………………

 

3. Has any claim such as would be covered by the proposed insurance ever been made

against this Practice/Firm or any of its Partners/Principals whilst in this or any other Practice/Firm

Yes No (please tick)

If ‘Yes’, please give full details: ………………………………………………………...

……………………………………………………………………………………………

4. Are any of the Partners/Principals or employees, AFTER FULL ENQUIRY, aware of any

circumstances or incidents which may give rise to a claim against this Practice/Firm pr their predecessors in business or any of the present former Partners/Principals?

Yes No (please tick)

 

If ‘Yes’, please give full details: …………………………………………………………...

………………………………………………………………………………………………

(We must stress that it is imperative you answer this question: FAILURE TO DO SO COULD WELL PREJUDICE YOU RIGHTS if subsequently, a claim should arise?

5. What is the amount of indemnity required? (Please indicate currency) ……………………
6. What is the amount of the excess which your Firm would be prepared to carry in respect

I/We declare that the statements and particulars in this 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 Insurers of any material alteration to these facts whether occurring before or after completion of the Contract of Insurance. Signing this Proposal Form does not bind the Proposer or Underwriter to complete this Insurance.

Dated this ………………..day of …………….20……..

FOR AND ON BEHALF OF ………………………………………………………………

SIGNATURE……………………………