Accountants professional indemnity insurance proposal form

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

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

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:

If you have answered 'YES' to (a), above a Financial Services Questionnaire will be required, please contact us for details. If you have answered 'YES' to (b) above please answer the following questions:

Please advise details of your present insurance

Your quotation requirements

Option 1

Option 2

Option 3

It 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.

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.

By completing this form you are agreeing for us to respond to you by post, telephone or email as appropriate.

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