Professional indemnity insurance - Agent Assure
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Proposal Online Form

Completing This Proposal Form

You may be aware that the Insurance Act 2015 makes various significant changes to insurance contract law. The Act applies to all non-consumer contracts (and some provisions also apply to consumer policies) subject to English law entered into (and all mid-term adjustments agreed) on or after 12 August 2016 and amongst other things, replaced the duty of disclosure for non-consumers with a duty to make a fair presentation of the risk. The new duty retains the core element of the existing duty of good faith but introduces some new clarifications regarding what is known by an insured and the format of disclosure. We set out below a summary of the new duty.

Duty of Fair Presentation
You are required to make a fair presentation of the risk to Insurers which discloses every material circumstance which you know or ought to know relating to the risk to be insured. This includes information known by your senior management and those responsible for arranging your insurance as well as information which would reasonably have been revealed by a reasonable search of information available to you. A circumstance is material if it would influence the judgment of a prudent insurer in determining whether to provide insurance for the risk and, if so, on what terms. Disclosure must be reasonably clear and accessible to a prudent insurer. Material representations of fact must be substantially correct and material representations of expectation/belief must be made in good faith. Failure to comply with the duty of fair presentation could mean that the policy is void or that Insurers are not liable to pay all or part of your claim(s). If you are in any doubt as to what may constitute a fair presentation, please feel free to contact us and we will endeavor to assist you.

Any insurance issued following completion of this proposal is subject to the policy terms and a specimen policy is available on request, from Gallagher.

Please answer all questions leaving no blank spaces. The form must be signed by the Principal or a Partner or a Director of the business. If you have a brochure about your Business Operations please forward it with this application.

No cover is in force until Gallagher have issued a quotation which has been accepted and Gallagher have confirmed that the policy has been effected.

Privacy Policy
Gallagher is the trading name of Arthur J. Gallagher Insurance Brokers Limited. We are the data controller of any personal information you provide to us or personal information that has been provided to us by a third party. We collect and process information about you in order to arrange insurance policies and to process claims. Your information is also used for business purposes such as fraud prevention and detection and financial management. This may involve sharing your information with third parties such as insurers, reinsurers, other brokers, claims handlers, loss adjusters, credit reference agencies, service providers, professional advisors, our regulators, police and government agencies or fraud prevention agencies.

We may record telephone calls to help us monitor and improve the service we provide. For further information on how your information is used and your rights in relation to your information please see our privacy policy. If you are providing personal data of another individual to us, you must tell them you are providing their information to us and show them a copy of this notice.

Your Company and Staff Your Activities Claims history Additional Requirements Finish

Section 1 - Your Company and Staff

1. Name of the Individual or Company(ies), including any Subsidiary Companies
and Trading Names for whom cover is required:
 
2. Date established:
 
 
3. Are you or any of the Partners or staff of your Practice/Firm admitted to membership of any Association or Professional Body e.g. RICS, NAEA Propertymark, ARLA Propertymark, NAVA Propertymark, ARMA?
 
4. a) Addresses of all the offices, including those of any overseas local offices
or representatives:
 
  b) E-mail Address:
 
  c) Telephone:
 
 
5. a) Please provide details of all Partners/Principals/Directors
   
Name & Position In the Company i.e. Director/Partner Age Qualifications and dates obtained e.g. FNAEA, MNAEA, MRICS, MARLA Number of years with the Company
  b) If a Sole Trader is this a part-time occupation?
 
  c) Is the Firm or any Partner or Director connected or associated (financially or otherwise) with any other practice, company or organisation? If YES, please give details.
   
  d) If cover is required for any retired or former Partner(s), Principal(s) or Director(s) please provide details below:
   
Names Age Position in Firm Period in this Firm Were they responsible for any previous claim?
6. Please provide details of any full-time and part-time Consultants who are, or have been in the past six years, under a contract of service with you and for whom cover is required under this policy:
   
Name of all Consultants Age Qualifications Date(s) Qualified No of years with you
7. Do you always obtain satisfactory written references when engaging Employees?
   
If 'NO', please provide the reasons and/or details of the procedures that you use YES NO
8. Please state the total number of:
   
a) Partners/Directors
b) Qualified Assistants & Consultants
c) All other staff (excluding
cleaners and the like)
  TOTAL NUMBER
9. Current insurance details:
   
a) Name of Insurer
b) Level of Indemnity
c) Excess applicable
d) Retroactive date
e) Expiry Date
f) Premium
10. Please confirm that only Partners/Directors have authority to close bank accounts? YES NO
N.B. If not currently insured the above information should be given relative to the last year of insurance cover
Next

Section 2 – Your Activities

11. Please state your Firm’s gross fee income/billings (including those paid to sub-contractors) in the last complete financial year, current year and your estimated fees for the forthcoming year payable by clients for work undertaken:
   
Year UK only Overseas excluding
USA & Canada
USA & Canada Total
Last year
Current year
Next year (estimate)
  Financial Year Ending (e.g. 31/12):

Annual wageroll


12. Please indicate the approximate percentage split in your fees (including payments to sub-contractors) or each of the following activities. THIS SPLIT MUST EQUAL 100%
a) Estate Agency inc. Probate, Matrimonial & Market Appraisals l) Building Society Agency
b)

Property Lettings:

m) Insurance Intermediaries
  i) Residential Property In respect of your activities as an insurance intermediary:
  ii) Commercial Property Do you transact Life Assurance
YES NO
c)

Property Management:

  If YES, are you a tied agent?
YES NO
  i) Residential Property If you are a tied agent, our Professional Indemnity Policy will not indemnify you, as this risk should be covered in your agreement with the Insurance Company concerned.
  ii) Commercial Property If however, you have answered ‘NO’, describe in the large box below the activities that you carry out
      n) Mortgage Broking
d) Residential Property Surveys & Valuations in
respect of lending purposes only. You would
need to complete a supplementary
questionnaire
o) If you engage independent or specialist consultants
e) Commercial Property Surveys & Valuations
in respect of lending purposes only. You
would need to complete a supplementary
questionnaire
 
i) % of fee income paid to them
f) Business Valuations
(Goodwill Assets & Property)
 
ii) Provide details of work undertaken in box below
g) Business Transfer
(Marketing & Sales of going concerns)
 
iii) Do you ensure they carry
their own PI insurance?
YES NO
h) Auctioneering   p) Other activities (please specify)
  i) Fine Art/Antiques  
  ii) Other (please specify) q) Home Condition Inspections/Reports
i) Architectural/Design   TOTAL
j) Project Management    
k) Project Co-ordination    
If asbestos surveys are undertaken, please advise as a separate additional proposal form will be required.
 
N.B. For any of the above types of works for which no income is shown please give details below if you have been
engaged in such activities in the last 5 years or intend to in the next 12 months.
 
13. Have you ever:
  a) Carried out any assessment, planning or reporting, or executed any plan of work as described in the Control of Asbestos at Work Regulations 2002 (CAWR)?
YES NO
  b) Provided any other advice, design or specification in relation to the manufacture, process, supply, use, removal or disposal of asbestos or any asbestos containing material?
YES NO
  c) Undertaken any survey or valuation work? (Excluding appraisals undertaken to establish a market price for sale or rental purposes or for probate, matrimonial and tax purposes)
YES NO
  d) Do you propose to undertake any of the above during the forthcoming period of insurance?
YES NO
  If you have answered YES to any of the above
questions it will be necessary to complete an
additional questionnaire
 
Next

Section 3 – Claims history

14.
Has any insurer If YES, please supply details
 
a) declined to insure you? YES NO
b) required special terms to insure you? YES NO
c) cancelled or refused to renew your insurance? YES NO
 
15.
FCA Status: If involved in general insurance or mortgage broking please provide details of FCA status
16.
Claims Experience: Professional Indemnity If YES, please supply details
 
a) Have any claims or prosecutions been made
against the Firm or its present
Directors/Partners (whether insured or not)?
YES NO
b) Are any of the Directors/Partners or
Employees after enquiry aware of any
circumstances, allegations or incidents which
may give rise to a claim against the Firm or its
predecessors in business or any of its present
or former Directors/Partners?
YES NO
 
17.
What amount of indemnity do you require? Please state amount
 
18.
Do you wish to contribute towards each and every
claim in addition to the minimum requirements
(Minimum excess £500, increased to £750 in
respect of Property Management and £1,000 where
limit of indemnity required is £1million or higher.)
YES NO
Please state amount
 
19.
Have you or any partner, principal or director ever If YES, please supply details
 
a) Been declared bankrupt or been disqualified
from being a company director or been
involved as owner, director or partner with any
company which went into receivership,
administration or liquidation.?
YES NO
b) Been the subject of (or have pending) any
County Court Judgements or Sheriff Court
Decrees?
YES NO
 
20.
Is there any other information in your
possession material to an assessment of the
risk to be insured?

If YES, please give details in the box below:
YES NO
 
 
Next

Section 4 – Additional Requirements

We would welcome the opportunity to provide you with access to our additional industry leading products and services. Please complete the information below and we will contact you at the appropriate time.
21.
Commercial Requirements:  
 
a) Office Policy YES NO
b) Public Liability YES NO
c) Employer's Liability YES NO
d) Director's & Officer's Liability YES NO
e) Cyber Liability YES NO
f) Motor Fleet YES NO
 
DATA PROTECTION
Any information which you supply, which you have previously supplied or which we may hold about you in the future may be shared
with other companies. The information may be held on our database which will allow us to keep you up to date with relevant
products and services and also support our service to you. The information may also be used for the prevention of fraud and for
statistical and research purposes. If you do not wish to be contacted with information of relevant products and services please write
to Gallagher, Custom House, The Waterfront, Level Street Brierley Hill, West Midlands, DY5 1XH.
For more detailed information as to how your personal data will be processed, please refer to the Privacy & Cookies section of our website.
 
DECLARATION

I/We warrant and declare that I/We have made full enquiry of all staff and that the particulars and statements in this proposal are true and complete and any other documentation and information provided in connection with this proposal are true and complete. I/We agree and accept that this proposal and declaration and the documentation and information which are provided (or should be provided) will be the basis of contract with Insurers.

I/We also warrant and declare that I/We have informed the Insurer of all facts which are likely to influence the Insurer in the assessment or acceptance of this proposal.

I/We understand that failure to inform Insurers of all material facts, including but not limited to any circumstance which might give rise to a claim, could invalidate this insurance. I/We accept that if I/We am/are in doubt whether any fact may influence the Insurer I/We should disclose it. I/We also understand that I/We have a continuing obligation to disclose all material facts up to commencement of and throughout the period of the policy.


Please tick this box to confirm your acceptance to the above.
Name :
Date :
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Arthur J. Gallagher Insurance Brokers Limited is authorised and regulated by the Financial Conduct Authority. Registered Office: Spectrum Building, 7th Floor, 55, Blythswood Street, Glasgow, G2 7AT. Registered in Scotland. Company Number: SC108909