Charities and Charitable Trusts Professional Indemnity Insurance

Proposed policyholder’s business activity:

If any other entities are to be covered, please list the names of such entities

 Proposed policyholder’s main office address:

How long has the proposed policyholder been established.

Does any one client represent more than 50% of the total income of the entities to be covered?

Is 20% or more of the total income of the entities to be covered paid to sub contractors?

Do the entities to be covered ensure that sub contractors are fully qualified and carry professional indemnity insurance? If No please give full details in the Additional Information Box below.

Has any insurer declined, cancelled or non-renewed any prior policy or application for professional indemnity or similar insurance of any of the entities to be covered? If Yes please give full details in the Additional Information Box below.

Has any entity to be covered been subject to any disciplinary or regulatory enquiry or proceedings or fines, penalties or other sanctions by a governmental, regulatory or professional body? If Yes please give full details in the Additional Information Box below.

Is any entity to be covered aware of any claim (whether insured or not) ever having been made against any entity to be covered or its predecessor? If Yes please give full details in the Additional Information Box below.

Is any entity to be covered aware of any facts or circumstances that may give rise to a claim against any entity to be covered or its predecessor? If Yes please give full details in the Additional Information Box below.

Largest contracts/projects carried out by the firm in the last five years

I declare and agree, on behalf of the proposed policyholder and all proposed insured's, that to the best of their knowledge and belief the statements set forth herein are true and that, if the Company agrees to insure, the material statements in this proposal or in any other information supplied, shall be the basis of the contract and shall be incorporated into and constitute part of the policy.

It is hereby agreed that the Company is authorised to make any investigation and inquiry in connection with this proposal that it deems necessary.