Online Premium Indication Form

Your name:*

First Last

Company name:*

Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Telephone number:

Fax:

Email:*

LI membership number:

Date:*

Fee income:*

Actual gross fee income for the LAST complete financial year or estimate for new start up.

Fees paid to sub-consultants:*

For sub-consultants who maintain a professional indemnity policy. If 'nil', enter '0'.

Fees - non-proceeded design work:*

If 'nil', enter '0'

Fees received from overseas work:*

If 'nil', enter '0'

What services does your practice provide?*

Please tick all that apply.

Other

Has the business been involved on project values EXCEEDING £500,000?*

Yes
No

Are you aware of any shortcomings in your work that could lead to a claim against you?*

Yes
No

Are you aware of any loss from the suspected dishonesty or malice of any employee or self-employed freelancer?*

Yes
No

Has any claim, whether successful or not, been made against you or your predecessors in business, or any past or present partner, principal, director or employee (whether previously insured or not)?*

Yes
No

Do you have a current Professional Indemnity Policy?*

Yes
No

If you answered 'yes' to current insurance arrangements, it is important you provide the following information:

Current limit of indemnity:

Current excess:

Current insurer:

Current broker:

Renewal date:

Retroactive date

Expiring premium:

Please specify the limits of indemnity required for indication purposes:

Online Premium Indication Form

Premium indication form