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, Principal or identified Officer of the firm.
4. If you have a brochure about your firm’s operations(s), please forward it with this application.

1. NAME OF FIRM:
2. ADDRESS OF FIRM: If more than one, please give each address and indicate Partner or Principal 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 Engineers ……….. h) Clerical ………..
3. Surveyors ……….. i) Typist, Office Boys ………..
4. Draughtsmen ……….. j) 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 covers during 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. IN WHICH OF THE FOLLOWING PROFESSIONS IS YOUR FIRM ENGAGED? PLEASE STATE APPROXIMATE PERCENTAGE:

1. Civil Engineering ………%
2. Structural Engineering ………%
3. Mechanical Engineering ………%
4. Electrical Engineering ………%
5. Heating & Ventilating ………%
6. Chemical Engineering ………%
7. Soil Engineering ………%
8. Nuclear Engineering ………%
9. Others, not shown please specify ………%

DESIGN AND REPORTS

Please indicate the approximate percentage of the total fees the Firm derives from

work where the main contract or interest is:

Approx. Percentage

(If None, State ‘None’)

1. Feasibility studies, reports, Surveys, etc

(where applicant is not involved in actual

design work) ………%

2. Bridge and/or Tunnels
3. Dams ………%
4. Mines ………%
5. Harbours or Jetties ………%
6. Sewerage schemes ………%
7. Foundations and Underpinning ………%
8. Soil Testing ………%
9. Water Schemes ………%
10. Nuclear or Atomic Projects ………%
11. Heating, Ventilating & Air-Conditioning ………%
12. Chemical, Petro-Chemicals and Refineries ………%
13. Housing Schemes (2-3 Floors) ………%
14. High Rise Building ………%
15. Schools, Hospitals, Municipal Buildings ………%
16. Industrialised Systems Buildings ………%
17. Mechanical Plant & Bulk Handling Equipment (including Silos, etc) ………%
18. Other work including any specialist activities not shown above

________

………%

========

9b. SUPERVISION OF CONSTRUCTION

1. Proportion of work where Firm both designs and supervises the ………%

Actual construction.

2. Proportion of work where Firm provides technical supervision of ………%

Construction from the design made by other Firms.

3. Proportion of work where FIRM provides design services but no ………%

………%

========

10. Does the Firm perform work overseas, or work for clients overseas?

Yes No (please tick)

If ‘Yes’, please give full details, and state countries involved.

 

11. CONSTRUCTION VALUES & FEES

Do the fees disclosed above include work performed on projects which have been aborted prior to commencement date, where no liability is accruing to the practice?

If so, please advise percentage of total fees applicable.

10. (APPLICABLE TO QUESTIONS 9 AND 10)

1. What substantial changes in the above percentages or amounts does the firm foresee

during the next twelve months?

2. Please give details of any major new operations being undertaken during next twelve

(C) Please comment on any features of your work which you think may be of interest to

Underwriters.

10. List the five largest jobs performed by your Firm and five typical jobs, giving brief

details of building values, fees received and a short description of contracts, performed

during last five years – to be listed on your Headed paper please.

11. Is this Practice or any Partner/Principal connected or associated (financially or otherwise)

with any other Practice, Company or Organisation?

Yes No (please tick)

If ‘Yes’, please give full details:

 

 

Is this Firm or any Partner/Principal or any associated Practice, Company or Organisation involved in any process of manufacture or construction?

Yes No (please tick)

If ‘Yes’, please give full details:

12. Is this Firm or any Partner or Principal a member of a Consortium?

Yes No (please tick)

 

If ‘Yes’, please state in what capacity and give the names of other members and their capacities in the Consortium.

NAME CAPACITY DETAILS OF JOB

 

 

 

 

 

 

 

 

 

 

13. 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:

 

14. 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 or their predecessors in business or any of the present or 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 YOUR RIGHTS if subsequently, a claim should arise?

15. Do you require insurance for:

1. Loss of documents Yes No (please tick)

B. Dishonesty of employees Yes No (please tick)

C. Libel and slander Yes No (please tick)

D. Professional Negligence Yes No (please tick)

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

(Underwriters require minimum excesses, depending on the size of Firm and type of work undertaken)

Before signing this proposal form please ensure that you have read the notice on the next page.

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……………………………

NOTE: In the case of a Company this form must be signed by a Director or Responsible and identified Officer. In the case of a Partnership it must be signed by the Principal or Partner.

It is essential that every proposer or Insured when seeking a quotation, taking out or renewing an Insurance, reveals to the prospective insurers any material facts or information (including any material circumstance or change in circumstance) which might influence the judgement of an insurer in fixing the premium or in determining whether he will accept the risk. Failure to do so may render the contract of Insurance voidable from inception at the option of the insurers and enable them to repudiate liability thereunder. If you have any doubt as to what constitutes a material fact or circumstance, please do not hesitate to seek our advice.