Product Design & Construct Professional Indemnity Proposal Form
The completion of this form in no way binds The Firm to purchase insurance, nor does it bind Underwriters to give insurance.
Any information given will only be passed to Underwriters for the purpose of obtaining a quotation and will be treated strictly as confidential.
1. Title/Company/Trading Name(s):
(include previous trading styles)
3. The Firms Business Description:
4. Primary Address:
5. Contact Telephone Number:
‘The Firm’
2. Date 1st Established:
6. Details of main Principals, Partners or Directors of The Firm:
Full Name
D.O.B
Qualifications
attach CV if available
attach CV if available
7. Please advise the following as an approximate percentage of The Firms work during the last complete financial year
(please estimate if no historical data):
Design and Construct from your own design and provide full supervision
Provide Design and Technical services, with no construction
Constructs from designs completed by others, on your behalf with out technical supervision
Constructs from designs completed by others & technical supervision is carried out (by other parties on your behalf, or by you)
Constructs from the design provided directly by the Principal, Employer or Client
Other Turnover not specified above please give details:
Total:
8. Please state number of (in-house, PAYE):
Directors/Principals
1.Design/Technical Staff (Fee Earners)
2.Manual Labourers
< Please include the Directors/Principals under the 3 categories above >
3.All other Staff
9 a. Are The Firms Key Persons (Fee Earners) covered in the event of Death/Illness/Disability?
b. Does The Firm have any locum agreements in force to ensure delivery of services if Fee Earners are incapacitated?
Yes
Yes
10 a. Percentage of the Gross Fees paid to independent Sub-Consultants (Design Professionals)
b. Would Sub-Consultants used hold their own Professional Indemnity Insurance?
c. What services does The Firms use independent sub-consultants for?:
%
Yes
No
11 a. Percentage of the Gross Fees paid to independent Sub-Contractors/Manufacturers (Labourers)
b. Would Sub-Contractors/Manufacturer used hold their own PI Insurance & PL/Product Liability?
c. What services does The Firms use independent Sub-Contractors/Manufacturers for?:
%
Yes
No
12. Where applicable please provide The Firms Turnover:
Total Gross Turnover received from Clients for financial year (14 to 15)
Total Gross Turnover received from Clients for financial year (15 to 16)
Total Gross Turnover received from Clients for financial year (16 to 17)
Estimate Gross Turnover for financial year (2017 to 2018)
Total
Turnover
UK Only
£
£
£
£
Total
Turnover
Elsewhere
£
£
£
£
%
%
%
%
%
%
100%
No
No
Income relating to
Design & Advice only
%
%
%
%
Important, Please read:
The above “Gross Turnover” figures should include all Service income received by The Firm from its clients including the cost of Materials, Wages, and
Payments made to Contractors and/or Specialist firms employed.
13. Is cover required for liabilities outside of U.K. jurisdiction?
Yes
No
14. Percentage of Gross Fees from abortive work, that has little likelihood of any future construction
%
15. Percentage of work undertaken where no Fees have been charged
%
16. Please advise how the following is established:
(a) User/Market Requirements
(b) Material Processes
(c) Product Constraints
(d) Manufacturing Requirements
(e) Budget / Costs
(f) Project Deadlines and Delivery
By The Firm
By The Client/3rd Party
Hammond Professional Indemnity Consultants Ltd | Please ring us on 01217883444 if you require any assistance.
Both
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Product Design & Construct Professional Indemnity Proposal Form
17. Does The Firm use Disclaimers or Standard Contract Terms
Yes
No
18. Does The Firm guarantee that a solution / deliverable will be reached
Yes
No
19. All work undertaken for the Client/Employer is checked and signed off by the Client before any implementation.
Yes
No
20. Approximate percentage split of work carried out in the following sectors (please estimate if no historical data):
Individuals
%
Start-ups
%
Small and medium-sized companies
%
International Corporations
%
21. Approximate percentage split of the industries which your clients/Employers generally belong to:
Medical
%
Retail
Recreation
%
Manufacturing / Processing
Computer/Electronic
%
Auto Mobile
Food
%
Government
Textile
%
Engineering / Construction
Communication
%
Travel, road/rail/maritime/aviation
Environmental
%
Media
Oil/Gas/Petrochemical/Nuclear industries
%
Other (please specify)
%
%
%
%
%
%
%
%
22. Would the failure of any products or services provided by The Firm liable to result in any of the following outcomes?
Loss of life or injury to a person
Yes
No
Destruction or damage to physical property
Yes
No
Immediate and large financial loss
Yes
No
Significant cumulative financial loss
Yes
No
Insignificant financial loss
Yes
No
A Product Recall Claim
Yes
No
23. Details of the 5 largest contracts/budgets in the last 5 financial years (if new business please skip to next question):
Description of the Works/Product
Description of Services Provided/Your Role
Total Project Value
Fees Earned
1
£
£
2
£
£
3
£
£
4
£
£
5
£
£
24. Details of the 3 largest contracts/budgets proposed to be undertaken in the next 12 months:
Description of the Works/Product
Description of Services Provided/Your Role
Total Project Value
1
£
2
£
3
£
Fees Earned
£
£
£
25. Please provide a general breakdown of The Firm Activities/Services provided; with % split – we appreciate that the categories of
works below will coincide partially or wholly (please estimate if no historical data):
Design of Aesthetics, Ergonomics, Anthropometrics only (no Electronic/Mechanical/Functionality)
%
Design of internal mechanisms, drives, electronics
%
Research Consultancy
%
General Concept Design and Development only
%
CAD Realization/Rendering/Analysis
%
Prototyping: 3D Print Technology only
%
Prototyping: Full working Models
%
Product Testing
%
Electrical Engineering
%
Final Product Manufacturing Services in House
%
Final Product Manufacturing Services via Third Party
%
Project Co-ordination
%
Project Management (The Firm is responsible for appointing other professionals/contractors)
%
Intellectual Property Consultancy
%
Management Consultancy & Business Development
%
Expert Witness, Feasibility
%
Other (please specify)
%
Total:
100%
26. If The Firm is involved in building of Prototypes, please provide details on the typical build process.
Hammond Professional Indemnity Consultants Ltd | Please ring us on 01217883444 if you require any assistance.
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Product Design & Construct Professional Indemnity Proposal Form
27. Claims and other Circumstance Statements
(a) No claims for professional negligence, error or omissions or the like have ever been made against The Firm or any
predecessor(s) in business or against any Partners/Directors/Principals either directly or in respect of any Company
of which they were a Partner/Director/Principal of.
True
False
(b) No Partner/Director/Principal has been personally involved in a PI claim/circumstance either whilst working on
his/her own account or for a practice/firm other than The Firm regardless of when the claim/circumstance occurred.
True
False
(c) After enquiry within The Firm the Proposer is not aware of any circumstances which have occurred which may
give rise to a claim.
True
False
(d) The Firm does not currently anticipate the need to institute litigation proceedings for recovery of any part of or
the whole of fees due to The Firms by any of its clients and has not received any intimation from any client of the
intention to withhold payment of any of The Firms fees.
True
False
(e) Any projects completed in the last 2 years were done so on an agreed time and budget, and all current projects
are also running on an agreed time and budget.
True
False
(f) The Firm or any Partners/Directors/Principal has not had any Insurers decline to offer PI renewal terms, nor has
had their PI policy cancelled or voided, or had any special premium increase or special terms being imposed due to a
material fact.
True
False
(g) The Firm or any Partners/Directors/Principal do not act, or have not acted, in any capacity other than those
declared.
True
False
(h) The Firm or any Partners/Directors/Principal are not currently a member of a Consortium nor has The Firm or
any Partners/Directors/Principal worked in the past in association with any other Firm or Organisation.
True
False
(i) The Firm or any Partners/Directors/Principal do not undertake work for any partnership, company or organisation
in which they are in a position to exercise a controlling interest in such a partnership, company, organisation.
True
False
If you answer ‘False’, to any of the questions above please provide details.
28. Does The Firm currently hold Professional Indemnity Insurance?
Current PI insurers/security:
Current PI broker:
Current Premium:
29. What PI Limit(s) of Indemnity does The Firm require?
30. Renewal Date/Cover Start Date
31. Professional Indemnity Excess
Yes
£
No
£
£
Please indicate below if you would like us to review any additional covers:
Public/Products Liability Insurance
Key Man Cover/Business Interruption
Commercial Legal Expenses (HMRC Queries, Contract disputes)
Cyber Liability – IT Hacker/Security Cover
Directors & Officers / Corporate Liability Insurance
Employers Liability (EL)
EL is Legally required for any “Ltd” Firms with 2≥ Directors
Contents/Computers Insurance
I/we declare that, after full enquiry, the contents of this proposal are true and that I/we have not misstated, omitted or suppressed any
material fact or information. I/we agree that this proposal together with any other information supplied by me/us shall form the basis
of any contract of insurance which may be affected. If there is any material alteration to the facts and information which I/we have
provided or any new material matter arises before the completion of the contract of insurance, I/we undertake to inform Underwriters.
Signature of Principal:
Date:
<Insurers do not accept electronically typed Names as signatures>
Please disclose any information/material facts which might influence the insurer in deciding whether or not to accept the risk:
Hammond Professional Indemnity Consultants Ltd | Please ring us on 01217883444 if you require any assistance.
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