UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE: NO 24 WHITES ROAD CHENNAI – 600 014
Proposal Form for Professional Indemnity

Applicable to Accountants / Solicitors / Lawyers / Counsels / Financial Consultants
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. Full details of work carried on
(Please attach brochure, information booklet, etc.
if any & specimen copy of contracts entered into)
4. i) Names in full of all Partners / Directors /
Principals
ii) Qualification in full
iii) Date qualified
iv) How long Principal in this practice
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 accountants / lawyers
ii) No. of professionals
iii)No. of administrative personnel including
clerks, typists, office boys, etc.,
iv) No. of apprentice
Total amount of annual wages payable
i)
ii)
iii)
iv)
6. 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).
7. Loss record for 5 Years:
Year Cause Kind of Loss Amount of Loss
19
19
19
19
19
8. 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)
9. Are you aware of any neglect, omission or error
or existence of any circumstances likely to give
rise to a claim?
10
a) Annual fees earned during the last five years
b) Estimated fees for the current year
Year Fee
11
.
Previous insurance history
1
2.
Limits of Indemnity required: Any one year
1
3.
Voluntary Excess if any
1
4.
Period of Insurance
From
To
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 agree that 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
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 of risk relating to lives
or property in India any rebate of the whole or part of the commission payable or any rebate of
premium shown in the policy nor shall any person taking out or renewing or continuing a policy
accept any rebate except such rebate as may be allowed in accordance with the published
prospectus or tables of the insurer.
2. Any person making default in complying with the provisions of this Section shall be punishable
with fine which may extend to Rs. 500/-.