Proposal Form for Professional Consultants

Please fill in the form below, and then click the submit button. You will then be provided with a quotation and to proceed simply print off this page, sign the declaration and return it to us with your cheque for the premium and insurance tax due. Upon receipt, cover will be issued and the appropriate Insurance confirmation will be sent to you. In the unlikely event that your proposal is not acceptable to Insurers your cheque will be returned immediately we receive it. Please note that cover does not incept until your proposal form has been accepted by Insurers.

Business details

Name of Business:
Address of Business:
Telephone Number:
Email address:
Date Established:

Select the option that most accurately describes your general activities:

Computing	White Collar Engineering
Interim Management	Business & Finance

If you have selected Computing

Please tick this box if you are a member
of the British Computer Society: Membership No:

If you have selected Interim Management

Please tick this box if you are a member
of the Institute of Interim Management: Membership No:

Details of Directors/Principals/Consultants of the business

Please give the following details of the Directors/Principals/Consultants of the business:

	Name	Relevant Qualifications / Experience
1.
2.
3.
4.

Number of:
practising Directors/Principals/Consultants other staff
NOTE: If numbers exceed those above,
please phone 020 7480 4180 for a quote.

Other information about the business

Please provide a full and clear description of your business activities:

My annual turnover is: £

Tick this box if your turnover averages more than £200,000 per director/principal/consultant per annum:

All policies will include £10,000,000 Employers' Liability cover when required by appropriate legislation. Please refer to the Description of Cover for this section and select whether or not required:

Please select amount of Professional Indemnity Required:
Please note this section of cover is on a "claims made" basis – please refer to the Policy Descriptions for further details

Please select amount of Public/Products Liability Required:

Please select Period of Cover Required:

Confirmation

We can confirm that:

the Directors/Principals/Consultants, after enquiry, are NOT aware of or suspect or have grounds for suspecting any circumstances which might give rise to a claim against the business or any present or former Directors/Principals/Consultants.
NO claim such as would be covered by the proposed insurance has ever been made against the company or any of its Directors/Principals/Consultants whilst in this or any other company.
NO insurer has ever declined a proposal or renewal for this business or any Director/Principal/Consultant.
We have read and accept DKPL's terms of business
We have had an opportunity to consider the specimen policy wording available on this site

Please click the Submit button to continue