Insurance Brokers, Leeds

Please provide a full answer to every question. The definitions at the end of this form should be read in conjunction with the form. This form must be signed by a Principal/Member/Director of the practice.

Please include all names under which you practice and any other entities for which you are seeking cover, including Trustee and/or Nominee Companies. Please provide a sheet of your headed notepaper.

Please state percentage totalling 100% of gross fees arising from the categories of clients listed below:

Has your practice, or any prior practice, reported any circumstances, incidents or claims to, Qualifying Insurers or the Assigned Risk Pool in the:

PLEASE NOTE THAT YOU HAVE AN OBLIGATION UNDER YOUR CURRENT PROFESSIONAL INDEMNITY POLICY TO NOTIFY ALL CIRCUMSTANCES AND CLAIMS AS SOON AS PRACTICABLY POSSIBLE. ALL SUCH NOTIFICATIONS OF WHICH YOU ARE AWARE THAT HAVE NOT BEEN REPORTED TO YOUR PREVIOUS INSURERS MUST BE NOTIFIED PRIOR TO THE EXPIRATION OF YOUR CURRENT POLICY

Please provide the percentage of Gross Fees allocated to each Area of Practice during the last financial year and the two prior years. Please round up to the nearest whole percentage.

Please request a Financial Services Questionnaire from us.

Personal Injury

Conveyancing

Wills & Probate

Do you have the required procedures in place throughout your firm for:

By signing this form I/we authorise J.M. Glendinning to obtain on our behalf all relevant claims prints relating to my firm and its predecessors.

Signing this form does not bind you to accept any quotation provided by J.M. Glendinning.

THIS PROPOSAL FORM MUST BE SIGNED BY A PRINCIPAL/MEMBER/DIRECTOR OF THE FIRM

All personal data collected by J.M. Glendinning (Insurance Brokers) Professional Risks Limited will be held in accordance with the Data Protection Act 1998. J.M. Glendinning will disclose this information to our service providers and agents for administration purposes and for underwriting and claims handling purposes. In addition J.M. Glendinning may exchange information with other organisations such as the police, regulatory authorities and professional bodies by whose rules we are bound, through various databases to help us check information provided and to prevent fraud. By returning this form, you consent to the processing of personal data, including sensitive personal data, for these purposes and to J.M. Glendinning transferring such information outside the European Economic Area where necessary.

When you provide information about another person, you are confirming that they have appointed you to act for them. Such persons will have been made aware of the purposes for the data collection and processing set out above and have consented to such processing. You will receive on their behalf any data protection notices and keep them informed about how their data will be processed and where it may be disclosed.

J.M. Glendinning may share personal data with other companies with which we establish commercial links so we and they may contact you (by mail, email, telephone or other appropriate means) in order to keep you informed about carefully selected products, services or offers that we believe will be of interest to you. If you do not wish us to do this please tick the box.

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.

By signing this form I/we authorise J.M. Glendinning to obtain on our behalf all relevant claims prints relating to my firm and its predecessors.

Signing this form does not bind you to accept any quotation provided by J.M. Glendinning.

THIS PROPOSAL FORM MUST BE SIGNED BY A PRINCIPAL/MEMBER/DIRECTOR OF THE FIRM