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ENGINEERS PROPOSAL FORM
Fields marked with * are required.
SECTION 1: DETAILS OF THE PROPOSER 
 
 
 
 
 
 
SECTION 2: PROFESSIONAL BUSINESS 
Currently Insured 
 
 
 
 
Activity Splits 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
FEES EARNED FROM 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
STAMP DUTY & TAXES SPLIT 
 
 
 
 
 
 
 
 
 
SECTION 3: GENERAL INFORMATION 
GENERAL QUESTIONS 
Upon enquiry, (a) has any claim(s) been made against your business or any partner, principal or director or any related entity to the Insured for professional negligence, error or omission in the past 5 years where the value of all claims notified exceed $20,000 including current reserves, or (b) are you or any partner, principal or director of the Insured aware of any circumstance or incident which may give rise to a claim under the policy? 
Upon enquiry, has any partner, principal, director or staff member of the Insured ever been subject to disciplinary proceedings for professional misconduct? 
Has your business, practice or any partner, principal or director ever been declined this type of insurance, or had similar insurance cancelled, or had an application for renewal declined (other than insurer exiting that area of insurance), or had special terms or restrictions imposed? 
INDUSTRY SPECIFIC QUESTIONS 
Are you professionally qualified for the activities you wish to insure? 
Do you conduct Business valuations, auditing of public listed companies, liquidation, insolvency or bankruptcy for public listed companies, financial planning, fund management or merger & acquisition activities? 
SECTION 4: INCOME DETAILS 
Fees 
 
 
 
SECTION 5: DECLARATION 
I/WE on behalf of the INSURED declare that the statements and particulars in this Declaration are true and that no material facts have been misstated or suppressed after enquiry. I/WE on behalf of the INSURED agree that should any of the information given by us alter between the date of this Declaration and the inception date of the insurance to which this proposal relates, I/WE will give immediate notice thereof. The undersigned agrees that this Declaration, together with any other information supplied by us, shall form the basis of any contract of insurance effected thereon. 
 


 

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