PROFESSIONAL INDEMNITY POLICY FOR ACCOUNTANTS AND LAWYERS PROPOSAL FORM
1. Name of Applicant
2. Address (Head Office)
Address (Branch Office) if any – indicate resident partner
3. When was the applicant established?
4. Has the name of the applicant been changed, any other business purchased or any merge or consolidation taken place during the past 5 years? Has the name of the applicant been changed, any other business purchased or any merge or consolidation taken place during the past 5 years? Yes No
If yes,give details
5. What are the dates or your applicant’s financial years?
6. To which professional associations, if any does your applicant belong to ?
7.What are the Gross fees for :
a) 12 months prior (audited)
b) 12 months expiring
c) Estimate for next 12 months
8.Does the Applicant practice extend or has it ever extended to activities in foreign countries? {ผู้เอาประกันได้ขยาย หรือเคยขยายกิจกรรมไปยังต่างประเทศ} Yes No
If yes, please indicate the approximate percentage of gross fees derived :
a) from domestic activities
b) from foreign activities
Total 100%
c) Which countries?
9.For Accountants Only
Indicate the approximate percentage of gross fees derived from the following activities :
| Type of work | % | Type of work | % |
| Audit | Corporate finance services (including due diligence, M&A, financing, capital / fund raising, capital restructuring) | ||
| Liquidation & insolvency | |||
| Investment advice & management | |||
| Tax planning & compliancet | Business valuation services | ||
| Bookkeeping & preparation of accounts | IT services (specify) | ||
| Internal audit services | Other consultancy (specify) | ||
| Company secretarial services | Payroll services | ||
| Total | 100% | ||
10.For Lawyers Only
Indicate the approximate percentage of gross fees derived from the following activities :
| Real Estate Conveyancing | % |
| Litigation | |
| Estate Work | |
| Commercial Matters | |
| Criminal Law | |
| Corporation | |
| Patents | |
| Others (please give details) | |
11.In respect of computer data records and programmes : Is your computer infrastructure (all hardware and all software) updated to meet compatibility with the year 1999/2000 data change problem (the so called millennium or Y2K problem) Yes No
If no, what are your current measures to meet Y2K compatibility ?
12. Practising partners or principles.
Name :
Qualification & Date Qualified :
How long practicing with this firm :
How long practicing with previous :
13. Former Partners Name :
Date of joining firm :
Date of leaving firm :
14. Total number of practicing partners,principals and staff : Partner or Principals :
Other equally qualified professionals :
Staff other than typists, telephonists, receptionists, office boys and messengers
15. Have any of those listed under item 13 ever been subject to disciplinary action by authorities as a result of their professional activities ? Yes No
if yes, please give details :
16. What amount of indemnity is required?
17. What amount of excess would the firm be prepared to carry in respect of each claim ?
18. Does the firm require indemnity of any or all of the following extensions for which extra premium is required ?
Retroactive Extension Yes No
Retroactive Date Required :
Why?
Partners Previous Business Extension
a) incoming partner Yes No
b) outgoing partners Yes No
if yes, please give names of those for whom insurance is required :
Incoming Partners :
Date of joining :
Period of cover required :
Outgoing Partners :
Date of leaving :
19. Has the firm in the past been insured for Professional Liability risks? Yes No
if yes, please answer the following : ถ้าใช่, โปรดตอบคำถามด้านล่าง
a) Date of first insurance :
b) Name of first insurance :
c) Excess borne by firm :
d) Amount of indemnity :
e) Expiry date of policy :
Is the firm at present insured for Professional Liability risks ? Yes No
If yes, please answer the following : a) Name of insurers :
b) Excess borne by firm :
c) Amount of indemnity :
d) Expiry date of policy :
e) Premium Paid :
Has insurance coverage between date of first covers and present application been interrupted? Yes No
If yes, please give details :
20. Has any application for insurance on behalf of the firm or their predecessors in business or any of the present partners or renewal refused? Yes No
If yes, please give details :
21. Are the partners or principals after enquiry, aware of any circumstances which may result in any claim being made against the firm, its predecessors in business or any of its present or former partners or principals ? Yes No
If yes, please give details :
DECLARATION : I /We declare that the statement and particulars in this proposal are true and that I/we have not misstated or supposed any material facts. I/We agree that this proposal, together with any other information supplied by me/us shall form basis of any contact of insurance effected hereon. I/We undertake to inform the Company of any material alteration to these facts occurring before or after completion of the contract of insurance.
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