Design & Construct Quote Request

Step 1 of 10

Details of the Proposer:

Name of Firm(s), (including trading names), of all entities to be Insured: Address(es) of the Firm: Website address: Establishment Date of Firm Is the Firm associated with or have any financial interest in any other Firm?
Yes No If Yes, please provide full details:

Please provide details of the Principals/Partners/Directors of the firm:

Please state total number of:

Principals/Partners/Directors Other Technical Staff Qualified Staff Administrative/Other

Step 2 of 10

Has the firm name ever changed?

Yes No

Has any other practice or business amalgamated or merged with you?

Yes No

Have you purchased any other practice or business?

Yes No If Yes to any of the above, please provide full details Does the Firm belong to any professional/regulatory bodies, trade associations or societies?

Step 3 of 10

Please provide a split of the professional work undertaken within your Design & Consulting Department in the previous and current year:

Architectural

Civil Engineering

Structural Engineering

Mechanical Engineering

Electrical Engineering

Heating and Ventilating Engineering

Chemical Engineering

Soil Engineering

Nuclear Engineering

Entertainment/Leisure Industry

Surveying - Land

Surveying - Quantity

Surveying - Building

Others

Fees paid to Consultants, Sub-contractors or Agents

Other work

Have your activities changed in the past 5 years or do you anticipate any major changes in these activities in the forthcoming 12 months. If so please provide full details:

Step 4 of 10

Please indicate the percentage of gross fees in the previous year that the following types of work represent:

Home building

Individual Dwellings

Low Rise Multiple Dwellings

High Rise Multiple Dwellings

Modular Dwellings (i.e. involving repetitive design)

Engineering Construction

Highways

Bridges, Tunnels and Dams

Railways, Airports, Harbours and Jetties

Sewerage / Water Schemes

Industrial

Power Plants

Refineries and Petro-Chemical Installations

Manufacturing Plants

Industrialised Systems Buildings

Amenities

Hospitals and Nursing Homes

Schools and Universities

Hotels and Recreation Centres

Other Specialist Construction

Do you engage in the manufacture or fabrication of any pre-engineered unit? If Yes, please provide full details: Please provide details of the type of work normally carried out:

Has the Firm ever failed to complete a project?

Yes No

Step 5 of 10

Please give details of Turnover

Turnover where firm designs and constructs from their own designs, and provide full technical supervision

Fess where firm provides design and technical services, where no construction is involved by the firm

Turnover where firm constructs from other’s designs performed on behalf of the firm

Turnover where firm constructs from other’s design and other’s technical supervision performed on behalf of the firm

Other turnover not mentioned above. Please give brief details

Please specify percentage split of income emanating from USA/Canada or work subject to USA/Canadian law:

Step 6 of 10

Please provide details of the 5 largest contracts undertaken in the last 5 years where the Design and Consultancy has been carried out by the Firm or where the Firm has sub-contracted the design work:

Please provide details of the largest 3 contracts (in terms of total project value) expected to commence in the next 12 months where you have responsibility for design or other professional services:

Step 7 of 10

Does the Firm use a standard form of contract, agreement or letter of appointment?

Yes No Does the Firm always confirm verbal report in writing? If no please explain:

Does the firm undertake any work which involves polluted land or property, or advise third parties as to whether or not land or property may be polluted or contaminated?

Yes No

If Yes, do you have a standard contract or terms of engagement which incorporates a disclamer or limitation of liability in respect of pollution and contamination?

Yes No If Yes, please confirm how long this has been used Does the Firm use the services of consultants, sub-contractors or agents? If Yes, do you require them to have PI Insurance and if so what limit of indemnity: What percentage of your income relates to sub-contracted work? Is or has the Firm been a member of a consortium, group practice, joint venture, strategic alliance or involved in any single project partnership? If Yes, please provide full details:

Step 8 of 10

Does the Company currently have a Professional Indemnity Insurance policy in force?

Yes No

If Yes:

Insurer Expiry Date Limit of indemnity Excess Premium Expiry Retroactive Date Has any previous policy for Professional Indemnity insurance been cancelled or refused or had any special terms imposed by any insurer? If Yes, please provide full details: Please indicate the Limit of Indemnity Required Please specify if other What Excess is the Proposer prepared to carry uninsured? Other

Step 9 of 10

Have any claims alleging negligent act, error or omission (successful or otherwise) been made against you, your predecessors in business, or present or past partners, principals or directors?

Yes No If Yes, have such matters been notified to current or previous Underwriters? If Yes, please provide full details:

Are you or any partners, directors or principals, after having made full enquires, including of all staff, aware of any of the following matters?

Any circumstances which may give rise to a claim against you, your predecessors in business or any past or present partner, director principal or employees?

The receipt of any complaints, whether oral or in writing, regarding services performed or advice given by you?

If Yes, please provide full details:

Step 10 of 10

Data Protection

The firm is a Data Controller as defined in the Data Protection Acts 1988 and 2003. We collect your personal details in order to provide business services to you. These details can be stored electronically or on paper for the purpose of arranging transactions on your behalf. We take great care with the information you provide to us, taking steps to keep it secure and ensure it is used only for legitimate purposes.

To provide you with services, we sometimes have to share your information including claims history with other relevant professionals (insurance companies, reinsurers, underwriters, claims handlers etc.) In assessing any claims made, insurers may undertake checks against publicly available information such as electoral roll, court judgments, bankruptcy and repossessions. We may also be obliged to share information with regulatory or statutory bodies.

You have the right at any time to request a copy of any “personal data” within the meaning of the above Data Protection Acts which the firm holds about you (a fee of €6.35 may be charged) and to have any inaccuracies corrected.

Declaration

The undersigned authorised Officer of the Company declares that the statement and particulars in this Proposal form are true and that no material facts have been misstated or suppressed after enquiry. The undersigned agrees that should any of the information alter between the date of this Proposal and inception date of the insurance to which this proposal relates, they will give immediate notice thereof. The undersigned agrees that this Proposal, together with any other information supplied by us shall form the basis of any contract of insurance effected thereon.

OBF