Optional – only complete this section if this insurance cover is required.
This insurance is not suitable for any business related to: life assurance, pensions, financial investment advice/consultancy, mortgage broking or building society tied agencies.
3.1 Your business activities
Please split your last completed financial year’s income approximately between the following professional disciplines. If this proposal form is being completed on behalf of a new business, please split your estimated fee income for the forthcoming year.
a.
Personal lines insurance:
i.
Motor
%
ii.
Other (including personal marine and aviation)
%
b.
Commercial lines insurance:
i.
Motor
%
ii.
Other
%
c.
Marine
%
d.
Aviation
%
e.
Reinsurance
%
f.
Non-regulated financial services business – please give full details:
%
g.
Other – please give full details:
%
3.2 Future business activities
Do you expect any significant changes to the split of activities shown in section 3.1 in the next 12 months?
Yes No
If Yes, please provide details:
3.3 Your largest insurance carriers
Please give details of the three largest carriers by commission generated past year:
Name of carrier
Commissions generated for last financial year:
£
£
£
3.4 Placing business
a.
Have you ever placed any insurance with insurers (including syndicates at Lloyd’s) not authorised by the Financial Conduct Authority (or the equivalent regulatory body in the EU)?
Yes No
If Yes, please give details:
b.
Have you ever been authorised to conduct investment business as defined by the Financial Services and Markets Act 2000?
Yes No
If Yes, please give details:
3.5 Underwriting agencies
a.
Have you ever placed business with an underwriting agency*?
Yes No
*Underwriting agency does not mean your own delegated authorities but refers to agencies underwriting an account of business for insurers.
If Yes, have you checked the validity of their authority and ensured that they are backed by FCA authorised insurers?
Yes No
b.
Please give the names of the underwriting agencies:
3.6 Largest business placed
Give the two largest sums insured that you place in respect of:
a.
Fire and perils (i.e. the material damage and business interruption combined exposure)
Nature of client’s business
Type of insurance
Total sum insured
Largest sum insured for any one location
£
£
£
£
b.
Public liability, products liability or professional indemnity risks:
Nature of client’s business
Type of insurance
Limit of liability
£
£
3.7 Delegated authorities
Do you hold any delegated binding authority granted by any insurer (including Lloyd’s syndicate) or reinsurer where you can set rates, terms, conditions, question sets, issue statements of fact or handle claims?
Yes No
If Yes, please complete a Hiscox Binding authority questionnaire.
Do you operate any other form of delegated authority whether on pre-set terms or not?
Yes No
If Yes, please give details:
3.8 Completing proposal forms
Have you ever completed proposal forms on behalf of your clients (not including computer generated ‘statement of fact’ based proposal forms)?
Yes No
If Yes, do you always ensure that the client signs the proposal or signs a dated disclaimer confirming the accuracy of the answers?
Yes No
3.9 Previous insurance
Have you ever bought professional indemnity insurance in the past?
Yes No
If Yes, please provide details of your most recent policy:
Name of insurer
Limit of indemnity
Excess
Premium
Renewal date
No. of years continuously held
£
£
3.10 Cover required
Limit of indemnity required:
£250,000
£500,000
£1,000,000
Other:
£
Section 4 - Management liability
Optional – only complete this section if cover for directors and officers’ liability, corporate legal liability and employment practices liability is required.
4.1 Directors and officers’ and corporate legal liability
Please provide confirmation that you and all of your subsidiaries:
a.
are a UK registered limited company;
Yes No
b.
are not listed on any stock exchange;
Yes No
c.
are not:
i.
a firm offering professional legal advice; or
ii.
a firm directly regulated by the Financial Conduct Authority or Prudential Regulation Authority; or
iii.
a recruitment consultant or staffing agency.
Yes No
d.
have been trading for at least two years;
Yes No
e.
have not made a loss in the last 12 months or do not expect to make a loss in the next 12 months;
Yes No
f.
Have declared a positive net worth in your latest annual accounts;
Yes No
g.
have not had your accountants qualify their opinion in your latest annual accounts;
Yes No
h.
have no assets in or turnover from the USA?
Yes No
i.
have reviewed your health and safety policies and procedures in the last 12 months;
Yes No
j.
segregate duties so that at least dual control exists on signing cheques, issuing instructions for disbursement of assets or funds, fund transfer procedures or investments for amounts in excess of £2,500.
Yes No
4.2 Employment practices liability
Employment practices liability can only be taken with directors and officers’ liability and corporate legal liability, it cannot be taken standalone.
Please confirm that you and all of your subsidiaries:
a.
have not made any redundancies in the last 12 months;
Yes No
b.
do not anticipate any redundancies in the next 12 months;
Yes No
c.
have written employment and grievance policies which are communicated to all new and existing employees;
Yes No
d.
review and gain approval from external legal or human resources advisers prior to any disciplinary action or employee contract terminations?
Yes No
If you have answered No to any of the above, please provide full details below (please attach additional sheet if necessary):
