Impotant Information

  1. AN INDIVIDUAL WHO ASSISTS AN APPLICANT TO COMPLETE AN APPLICATION OR PROPOSAL FORM FOR INSURANCE SHALL BE DEEMED TO HAVE DONE SO AS THE AGENT OF THE APPLICANT IN ACCORDANCE WITH SECTION 54(2), INSURANCE ACT, 2003

  2. THE LIABILITY OF THE COMPANY DOES NOT COMMENCE UNTIL THIS APPLICATION IS ACCEPTED AND THE PREMIUM IS PAID IN ACCORDANCE WITH SECTION 50(1) OF INSURANCE ACT 2003

    1. Principal Officers Designation BVN

  18. State your full professional activities (please attach company’s corporate profile)

  19. How long have you been in operation

  20. No. of Professional Staff

  21. Please input a tabled list of Principals/Directors Particulars with the following Headers:
    1. Name Age Qualification

  22. Are you a member of a good standing profession association/Regulatory body

    If yes, please specify

  23. Gross Professional Fees/Earnings for the last 1 year

  26. List of Indemnity Required

  27. Does the Proposer ensure that Sub Consultants are engaged in a binding contract accepting responsibility for their own negligence, error or omission and does the proposer ensure that all Sub Consultants carry Professional Indemnity Insurance

  28. Does the Insured maintain a Complaints Register on all complaints it receives from clients

  29. Does the proposer have written procedures or checklists for the service performed

  30. Does the Proposer currently have Professional Indemnity Insurance in force

    If yes provide the following details

    please input a tabled list with the following headers

    1. Name of insurer
    2. Period of insurance
    3. Sum Insured
    4. Premium
    5. Excess

  31. Have you suffered any of loss(es) in the past

    If yes provide the following details

    please input a tabled list with the following headers

    1. Year
    2. Insurer
    3. Claimant
    4. Nature of Problem
    5. Amount Paid/ Outstanding

  32. Has any company declined, cancelled, refused or accepted your proposal on special terms and conditions

    If yes give details in a separate sheet

  33. Do you have any other existing policies

    If yes give details in a separate sheet

Declaration

I/We warranted that the above statements are true and complete and I/We agree that this proposal shall be the basis of the contract between me/us and the Company

I/We agree to accept a policy in the Company’s usual form for this class of insurance

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