Accountants PI Online Proposal 1-4 partners

Practice Details

Practice name*

Main office address*

Postcode*

Date Established*

Contact telephone number*

Contact fax number

Contact e-mail address*

Partners / Directors / Members

Name of Partner/Director/Member

Qualifications

Date Qualified

How long as Partner/Director/Member of the Firm(s)

Name of Partner/Director/Member

Qualifications

Date Qualified

How long as Partner/Director/Member of the Firm(s)

Name of Partner/Director/Member

Qualifications

Date Qualified

How long as Partner/Director/Member of the Firm(s)

Name of Partner/Director/Member

Qualifications

Date Qualified

How long as Partner/Director/Member of the Firm(s)

Is cover required for any partner or director in respect of his/her liability arising from any previous business? If 'Yes', please provide details below

No Yes

Staff Details

Please advise total number of staff excluding partners/directors/members

Professionally Qualified

Unqualified Assistants

All Others (e.g. secretarial)

Gross fee income

Last Financial Year

Largest Fee from any one client

Fees paid to sub consultants

If this proposal is for a new firm, provide estimate figures for the first year

Split of work

Audit, Accountancy, Company & Personal Tax %

Other Taxation Consultancy Services (not personal) %

Insolvencies, Liquidations & Receiverships %

Executorships, Directorships & Trusteeships %

Financial Services %

Corporate Finance %

Mergers, Acquisitions & Disposals %

All other work (please give details) %

Details of 'All Other Work':

Do you undertake any work for Banks and other Financial Institutions, Insurance Companies, Lloyds Syndicates, Funds or Managing Agents (including Captive Insurance Companies), Offshore Companies, or PLCs? If 'Yes', please provide details below.

No Yes

Have you undertaken any work for any entertainment or professional sports client(s) where you have obtained an individual fee greater than £5,000 in any one Financial Year? If 'Yes', please provide details below.

No Yes

Overseas Work

Have you undertaken any work for any clients based outside of the UK or for clients based in the Channel Islands or Isle of Man during the past six years? If yes, please provide details for each client below including the nature and turnover of their business, their location, the fee(s) earned for each of the last three years and the services provided.

No Yes

Trusts

Does any Partner/Director/Member/member or employee of the Company/Firm act as a sole Trustee or have sole discretionary powers for any Trust(s)? if 'Yes', please provide details below:

No Yes

Financial services

Have you or any firm you have acquired, ever carried out any regulated activities as defined in the Financial Services and Markets Act 2000 (other than in connection with general insurance products) as:

Claims and circumstances

After a FULL ENQUIRY are you aware of any claim against the Firm(s) or its predecessors in business or the present or former partners/directors, or any circumstances, allegations or incidents which may give rise to a claim? If 'Yes', please provide details below:

No Yes

Fraud and dishonesty

Are you aware of any fraud or dishonesty of any partner, director, member or employees of the firm? If 'Yes', please provide details below, including measures taken to prevent recurrence:

No Yes

Disciplinary actions

Has any Partner/Director/Member/member or employee, either past or present, during the last six years been subject of a disciplinary proceeding by any professional organisation? If 'Yes', please provide details below:

No Yes

Current insurance and future requirements

Please advise details of your present insurance

Insurer

Renewal Date

Limit of Indemnity

Excess

Premium

Your quotation requirements

Option 1

Limit of Indemnity

Excess

Option 2

Limit of Indemnity

Excess

Option 3

Limit of Indemnity

Excess

Attach additional information

If you would like to attach more information, please upload your file here.

Disclosure of Material Facts

IIt is essential that every Proposer or Insured when seeking a quotation, taking out or renewing an insurance, reveals to the prospective Insurers any material facts or information (including any material circumstances or change in circumstance) which might influence the judgement of Insurers in fixing the premium or in determining whether they will accept the risk. Failure to do so may render the contract of insurance voidable from inception at the option of the Insurers and enable them to repudiate liability thereunder. If you have any doubt as to what constitutes a material fact or circumstance, seek our advice.

Declaration

By submitting this form, I declare that the above statements and particulars are true, full enquiry having been made, and I have not omitted, suppressed or mis-stated any material facts and undertake to inform the Insurer of any change to any material fact. I understand that the information I provide will be used in deciding the price charged by the Insurer for the risk and whether the Insurer will accept the application. I further agree that this declaration, together with any other information provided shall be the basis of any contract between me and the Insurer.

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Accountants PI Online Proposal 1-4 partners

Your quotation requirements

A copy of this application form will be emailed back to you once submitted and should be retained by you for your own records