UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE NO 24 WHITES ROAD CHENNAI – 600 014
Proposal Form for Professional Indemnity Insurance
Applicable to Consulting Engineers, Architects and Interior Decorators

This proposal must be signed. All questions must be answered. The completion and signature of this
proposal does not bind the proposer or Insurer to complete a contract of Insurance.
If there is insufficient space to answer questions, please use additional sheets and attach it to this form.
The Company does not assume any liabilities until the Proposal has been accepted and premium paid.
1. Name & Address of Proposer
2. When established
3. Description of the Business:
(Please attach brochure, information booklet, etc.)
4. a) i) Names in full of all Partners/Directors/Principals
ii) Qualifications in full
iii) Date qualified
iv) How long Principal in this practice
b) Is coverage required in respect of past work for any
Partner/Principal who has left, retired or died? Yes/No.
If ‘Yes’ please give the following
i) Full Name
ii) Qualifications
iii) How long Principal in this practice
i)
ii)
iii)
iv)
i)
ii)
iii)
5. State:
a) i) No. of qualified engineers
ii) No. of draftsmen
iii) No. of administrative personnel including clerks,
typists, office boys, etc.,
b) Specify nature of supervision exercised over the
employees
c) Total amount of annual wages payable
i)
ii)
iii)
6. a) Please state the 5 largest contracts where construction has commenced during the past 6 years.
Sl.
No. Starting Date Type of Contract Total Contract
Value Rs. Approx. Comp. Date
12345
b) Please give details of Contracts where construction is expected to commence in the next 12
months
Sl.No. Starting Date Type of
Contract
Total Contract
Value Rs. Approx. Comp. Date
7. State whether you undertake supervision of Contract works
being executed?
If yes, periodicity of inspection with details.
8. Do you engage persons outside your organisation?
If yes, specify the details of purpose and nature of control
exercised by you over them (specimen contract be enclosed)
9. Loss record for 5 years:
Year Cause Kind of
Loss
Amount of
Loss
Rs.
19
19
19
19
19
10. Have you during the past 12 months dismissed or do you
contemplate dismissal of any member of staff on account of any
omission, neglect, error or for like (please give full details)
11. Are you aware of any neglect, omission or error or existence of
any circumstances likely to give rise to a claim?
12. (a) Please give gross fees received during the past five years
b) Estimated fees for the coming 12 months
19------------Rs.--------------
19------------Rs.--------------
19------------Rs.--------------
19------------Rs.--------------
19------------Rs.--------------
Rs.
13. Has any Company
(a) declined your proposal
(b) required an increased premium
(c) refused to renew your policy
(d) cancelled such a policy
a)
b)
c)
d)
14. Limits of Indemnity required : Any one year
15. Period of Insurance required
From
To
16. Voluntary Excess, if any Rs.
17. Any other relevant information not stated above
I/We hereby declare that the above statement and particulars are true and I/we have not suppressed or
misstated any material facts and that at the present time I/we have no reason to anticipate any claim
being brought against me/us for any negligent act, error or omission on my/our part and against the
company and agree that this declaration shall be the basis of the contract between me/us and the
Insurer. I/We also agrethat the indemnity under the Insurance shall not be availed for claims arising out
of acts of negligence, error or omission or misconduct committed prior to commencement of this
insurance.
Date :
Place : Signature of Proposer
SECTION 41 OF THE INSURANCE ACT 1938 - PROHIBITION OF REBATES
1. No person shall allow or offer to allow either directly or indirectly as an inducement to any person
to take out or renew or continue an insurance in respect of any kind or risk relating to lives or
property in India any rebate of the whole or part of the commission payable or any rebate of the
premium shown on the policy nor shall any person taking out or continuing a policy accept any
rebate except such rebate as may be allowed in accordance with the prospectus or tables of the
Insurer.
Any person making default in complying with the provisions of this Section shall be punishable with
fine, which may extend to Rs.500/-.