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Design & Construct Quote Request

Professional Indemnity Insurance Form

Please Note:

  • This is a proposal form for a policy relating to claims made against the Insured during the period of the policy online - CLAIMS MADE.
  • Please answer all the questions giving full and complete answers. Please use a separate sheet of paper if insufficient space. If necessary please write additional relevant facts on a separate sheet of paper.
  • The proposal form must be completed and signed & dated by a person who is of legal capacity and have the authorisation to request this insurance for the Proposer.
  • This form does not bind the Proposer but will form part of the Insurance contract if taken up.
  • All material facts must be disclosed, as failure to do so may render any policy or cerfiticate voidable, or severely prejudice your rights in the event of any claim. A material fact is one likely to influence acceptance or assessment of the proposal by Underwriters. If you are in doubt as to what constitutes a material fact, you should consult your broker.

Please supply the following additional information:

  • CV's of Principals
  • Copy of Standard Contract Terms and Conditions (if applicable)

 

Step 1 of 10

Details of the Proposer:

Please state total number of:

Step 2 of 10

Has the firm name ever changed?

Has any other practice or business amalgamated or merged with you?

Have you purchased any other practice or business?

Step 3 of 10

Please provide a split of the professional work undertaken within your Design & Consulting Department in the previous and current year:

Architectural

Civil Engineering

Structural Engineering

Mechanical Engineering

Electrical Engineering

Heating and Ventilating Engineering

Chemical Engineering

Soil Engineering

Nuclear Engineering

Entertainment/Leisure Industry

Surveying - Land

Surveying - Quantity

Surveying - Building

Others

Fees paid to Consultants, Sub-contractors or Agents

Other work

Step 4 of 10

Please indicate the percentage of gross fees in the previous year that the following types of work represent:

Home building

Engineering Construction

Industrial

Amenities

Has the Firm ever failed to complete a project?

Step 5 of 10

Please give details of Turnover

Step 6 of 10

Please provide details of the 5 largest contracts undertaken in the last 5 years where the Design and Consultancy has been carried out by the Firm or where the Firm has sub-contracted the design work:

Please provide details of the largest 3 contracts (in terms of total project value) expected to commence in the next 12 months where you have responsibility for design or other professional services:

Step 7 of 10

Does the Firm use a standard form of contract, agreement or letter of appointment?

Does the firm undertake any work which involves polluted land or property, or advise third parties as to whether or not land or property may be polluted or contaminated?

If Yes, do you have a standard contract or terms of engagement which incorporates a disclamer or limitation of liability in respect of pollution and contamination?

Step 8 of 10

Does the Company currently have a Professional Indemnity Insurance policy in force?

If Yes:

Step 9 of 10

Have any claims alleging negligent act, error or omission (successful or otherwise) been made against you, your predecessors in business, or present or past partners, principals or directors?

Are you or any partners, directors or principals, after having made full enquires, including of all staff, aware of any of the following matters?

Any circumstances which may give rise to a claim against you, your predecessors in business or any past or present partner, director principal or employees?

The receipt of any complaints, whether oral or in writing, regarding services performed or advice given by you?

Step 10 of 10

Data Protection

The firm is a Data Controller as defined in the Data Protection Acts 1988 and 2003. We collect your personal details in order to provide business services to you. These details can be stored electronically or on paper for the purpose of arranging transactions on your behalf. We take great care with the information you provide to us, taking steps to keep it secure and ensure it is used only for legitimate purposes.

To provide you with services, we sometimes have to share your information including claims history with other relevant professionals (insurance companies, reinsurers, underwriters, claims handlers etc.) In assessing any claims made, insurers may undertake checks against publicly available information such as electoral roll, court judgments, bankruptcy and repossessions. We may also be obliged to share information with regulatory or statutory bodies.

You have the right at any time to request a copy of any “personal data” within the meaning of the above Data Protection Acts which the firm holds about you (a fee of €6.35 may be charged) and to have any inaccuracies corrected.

Declaration

The undersigned authorised Officer of the Company declares that the statement and particulars in this Proposal form are true and that no material facts have been misstated or suppressed after enquiry. The undersigned agrees that should any of the information alter between the date of this Proposal and inception date of the insurance to which this proposal relates, they will give immediate notice thereof. The undersigned agrees that this Proposal, together with any other information supplied by us shall form the basis of any contract of insurance effected thereon.

Learn more about our data protection policy.