Professional Indemnity Insurance Form

Professional Indemnity Insurance Quote Form


	DETAILS :
	Name of Practice:*
	Address:



	Postcode:
	Tel Number:*
	Website:
	Email:*

	Establishment Date:
	Number of directors/partners:
	Number of all other staff:
	Please select your profession from the following list:
	Please select a fee band applicable for your last 12 months trading: (or anticipated income if new business)
	If fee income exceeds £500,000, please state exact amount:


	Accountancy
	Please provide an approximate percentage split of your fee income in the following:

	Accounting and compliance taxation – quoted/public companies
	Accounting and compliance taxation – other
	Auditing – quoted/public companies
	Auditing – other
	Bookkeeping
	Directorship
	Executorships and Trustees
	Insolvencies, Liquidation and Receiverships
	Insurance, Building Society, Stock Exchange/Investment Commission
	IT Consultancy
	Management Consultancy
	Mergers, Acquisitions, Disposals
	Taxation (consultancy only)
	Payroll Services
	Secretarial and Share Registration
	If others please describe:

	Design & Construct
	Working Environment
	Please provide an approximate percentage split of your fee income in the following:

	Bridges
	Dams
	Mines
	Harbours or Jetties
	Sewage Schemes
	Foundations and Underpinning
	Water Schemes
	Nuclear or Atomic Projects
	Chemical, Petro-Chemical and Refineries
	Housing Schemes (2-3 floors)
	High Rise Buildings
	Schools, Hospitals, Municipal Buildings
	Commercial / Industrial Systems Buildings
	Merchant Plant and Bulk Handling Equipment
	Leisure Centres
	Swimming Pools
	Churches / Ecclesiastical
	Roads / Highways / Motorways
	Cladding / Glazing / Curtain Walling
	Roofing
	Airports
	Railways
	Amusement Parks
	Aviation / Automotive / Military / Marine
	Demolition
	Flooring
	If others please describe:

Type of Work	Design and Build Only	Design Only
Adjudicator/Arbitrator
Architectural Services as Defined in Work Stages C-L of RIBA Architects Appointment
Building Surveying
Consultancy Engineering – Civil
Consultancy Engineering – Structural
Consultancy Engineering - Environmental
Consultancy Engineering - Geotechnical
Consultancy Engineering – Mechanical
Consultancy Engineering – Electrical
Consultancy Engineering – Heating & Ventilation
Expert Witness
Feasibility Studies
Interior Design
Landscape
Non Structural Refurbishment
Town Planning / Consultancy
Planning Supervisor
Project Co-ordinator
Project Management
Quantity Surveying and Surveying (not listed above)
Structural Surveys/Reports/Valuations
If others please describe:

Financial Year Status	Previous	Last Complete	Current (Estimate)
Financial Year End (dd/mm/yy)
Turnover where the firm(s) design & constructs from their own design and provides full technical supervision
Turnover of those departments where the firm(s) providesdesign & technical services where no construction isinvolved by firm(s)
Turnover where the firm(s) constructs from other designs preformed on behalf of firm(s)
Turnover where firm(s) constructs from other’s designand technical supervision preformed on behalf of the firm(s)
Other turnover not mentioned

	Engineer
	Please provide an approximate percentage split of your work carried out:

	Bridges
	Dams
	Mines
	Harbours or Jetties
	Sewage Schemes
	Foundations and Underpinning
	Water Schemes
	Nuclear or Atomic Projects
	Chemical, Petro-Chemical and Refineries
	Housing Schemes (2-3 floors)
	High Rise Buildings
	Schools, Hospitals, Municipal buildings
	Commercial / Industrial Systems Buildings
	Merchant Plant and Bulk Handling Equipment
	Leisure Centers
	Swimming Pools
	Churches / Ecclesiastical
	Roads / Highways / Motorways
	Cladding / Glazing / Curtain Walling
	Roofing
	Airports
	Railways
	Amusement Parks
	Aviation / Automotive / Military / Marine
	Demolition
	Flooring
	If others please describe:

Please give the split of gross fees recieved in the last complete financial year:

	United Kingdom	Overseas Contracts
Consulting Engineering
Civil
Structural
Soil & Foundation
Mechanical
Electrical
Heating & Ventilation
Architectural
Town Planning / Quantity Surveying
Structural Surveying Inspection Reports
Valutations on Existing Property
Planning Supervision
Adjudication / Arbitrator
Expert Witness
Any work other than listed above, please give full details:

	Estate Agents
	Please provide an approximate percentage split of your fee income in the following:

	Estate Agency including Probate, Matrimonial & Market Appraisal
	Management Letting's – Residential Properties
	Management Letting's – Commercial Properties
	If others please describe:

	Financial Advisor
	Please provide an approximate percentage split of your fee income in the following:

	Pensions
	Endowments
	Other Life
	Mortgages
	Building Society Agencies
	PHI Medical
	Private Client Portfolio Management (Discretionary)
	Private Client Portfolio Management (Non-Discretionary)
	Investment In Unit Trusts / Insurance Bonds
	Dealing in Listed, Unlisted UK or Foreign Securities
	Dealing in Bonds (e.g. Euro Dollar) or Commodities
	Structured Capital at Risk Products
	Split Capital Investment Trusts / Zero Dividend Preference Shares
	Income Drawdowns
	If others please describe:

	Insurance Broker
	Please provide an approximate percentage split of your fee income in the following:
	Personal Lines
	Commercial Lines
	Professional Indemnity
	Construction
	Aviation
	Marine
	Risk Management / Consultancy
	If others please describe:

	IT Consultants
	Please provide an approximate percentage split of your fee income in the following:

	Hardware Sales
	Hardware Installation / Maintenance
	Software Product Sales
	Software Services
	Internet Services
	If others please describe:

	Management Consultants
	Please provide an approximate percentage split of your fee income in the following:

	Strategic Consultants
	Organisation, Design & Development Consultancy
	Quality Management
	Manufacturing Systems Consultancy
	Financial Management – Consultant only
	Project Management
	Human Resources Consultancy
	Recruitment Consultancy (Permanent Staff)
	Recruitment Consultancy (Temporary Staff)
	Marketing Consultancy
	Telecommunications Consultancy
	Computer & IT Consultancy
	Outsourcing & Facilities Management Consultancy
	Design & Creativity Consultancy
	Quality Assurance Consultancy
	Health & Safety Consultancy
	Interim / Locum Management
	Training Services
	If others please describe:

	Marketing & Media
	Please provide an approximate percentage split of your fee income in the following:

	Commercial TV – Production of Advertisements
	Commercial TV – Media Space Purchased
	Other Media – Production of Advertisements
	Other Media – Media Space Purchased
	Production of Printed Literature/Documents
	Direct Marketing
	Telemarketing
	List Broking
	Sales Promotion
	Marketing
	Market Research
	Public Relations
	Specialist Design
	Corporate Identity Work
	Event/Conference Organisation
	Multimedia Consultancy
	If others please describe:

	Recruitment Consultant
	Please provide an approximate percentage split of your fee income in the following:

	Clerical IT
	Other Professionals
	Medical/Nursing/Care
	Drivers/Warehouseman
	Blue Collar / Manufacturing
	Construction Manual
	If others please describe:

	Solicitors
	Please provide an approximate percentage split of your fee income in the following:

	Adjudication / Arbitration
	Agency Advocacy
	Children Work, Mental Health Tribunal & Welfare
	Commercial/Corporate Excluding Public Companies
	Commercial/Corporate Including Public Companies
	Commercial Litigation
	Conveyancing Commercial
	Conveyancing Residential
	Criminal
	Debt Collection
	Defendant Litigation (Insurers)
	Employment
	Estate Agency, Property Management & Valuation
	Expert Witness / Lecturing Work
	Financial Advice – Regulated by the SRA
	Financial Advice – Regulated by the FSA
	Immigration
	Intellectual Property Including Patent, Trademark & Copyright
	Landlord / Tenant
	Marine Litigation
	Matrimonial Family
	Oaths, Affidavits & Notary Public
	Offices and Appointments
	Parliamentary Agency
	Personal Injury (Claimant)
	Personal Injury (Defendant)
	Probate and Estate Administration
	Town & Country Planning
	Wills Trusts & Tax Planning
	Litigation Work (other)
	Non Litigation (Other)
	If others please describe:

	In the last 10 years has any fee earner in the firm ever:

	Been refused a practising certificate?

	Been granted a conditional practising certificate:

	Been the subject of a costs or penalty order or been reprimanded by the Solicitors Disciplinary Tribunal:

	Practised in a firm that has been subject to an investigation or intervention by any regulatory department of the Law Society or Solicitors Regulation Authority including the Office for the Supervision of Solicitors (OSS), Consumer Complaints Service (CCS) or the Legal Complaints Service (LCS)?

	Been investigated by any other regulatory body other than the Law Society (e.g. FSA)

	Had a civil or criminal judgement (other than minor traffic offences) against him or her?

	Had an award for inadequate professional service made against him or her by the OSS/CCS/LCS in the past 10 years?

	Has your practise been in correspondence with and/or recieved a formal visit from the Investigating Account of the OSS/CCS/LCS or any other proper officer of the OSS/CCS/LCS in the past 10 years?

	If 'yes' to any of the above, please provide full details and include all reports issued by the SDT, OSS, CCS, LCS and/or any other regulatory body:

	Any Other Miscellaneous Professions

	Please give details of your full business activities with approximate work splits in percentages:	(e.g. Private Invgestigator, Event Organiser, Interior Designer, etc)

	Claims History
	Have you had any claims in the past 5 years?
	If Yes, please provide full details of all claims:

	Additional Information
	Please state any other additional information that you would like to make us aware of:

©2007 Professional Indemnity Quote Direct. All rights reserved. W E Bedford Insurance Services (Wimbledon) Ltd, 267-269 Kingston Road, Wimbledon, London, SW19 3FW is authorised and regulated by the Financial Services Authority. Our FSA Register number is 305737