UNITED INDIA INSURANCE COMPANY LIMITED
REGD & HEAD OFFICE NO 24 WHITES ROAD CHENNAI – 600 014

PROPOSAL FORM FOR PROFESSIONAL INDEMNITY INSURANCE

1. a) Name of Proposer (in full)
b) Address
c) Telephone Number
a)
b)
c)
2. When was the Firm/ Company established?
3. a) In which type of profession is the Proposer mainly engaged?
Give full details.
b) Apart from the above, is there any other professional work
which the Proposer undertakes? If so, give details.
a)
b)
4. a) Does the Proposer conduct business from offices other than
the above? If so, please state the full address (es) of all such
offices.
b) Is there a Partner / Director in full time attendance at every
office?
a)
b)
5. Please give the following particulars for each Partner / Director:
Full Name Age Professional
Qualifications Date How long in practice as Partner /
Director
6. a) What establishment does the Proposer maintain to carry on
professional work?
b) Does the Proposer engage the services of professionally
qualified persons such as Chartered Accountants, Engineers
etc.?
c) Are they the Proposer’s full time employees?
a)
b)
c)
7. Please state the total number of
a) Partners / Directors
b) Staff other than Typist and Office Boys (Officers, Apprentices,
Articled Clerks etc., should be separately shown).
c) Typists and Office Boys
a)
b)
c)
8. Has the Proposer or have the Proposer’s predecessors in business
discharged or is the Proposer contemplating the discharge of any
employee for
a) Any negligent act, error or omission
b) Any dishonest, fraudulent, criminal or malicious conduct? if
so, give full details
a)
b)
9. Is the Proposer now or ever been insured against professional
indemnity risks? If so, state with what Company or Companies?
10. a) Has any one made any claim for breach of professional duty a)
against the Proposer or the Proposer’s predecessors in business
or against any Partner / Director individually or has the
Proposer any reason to suspect that such a claim could be
made? If so, give full particulars.
b) Give below particulars of all professional indemnity claims
made by the Proposer or the Proposer’s predecessors in
business during the past five years.
b)
Year No. of Events No. of Insurers Amount
recovered Rs. Amount to be recovered Rs.
19
19
19
19
19
11. Is there any other information material to the risk in
the Proposer’s possession? If so, give full details.
12. Has any insurer previously granted a cover in
respect of the risk proposed for insurance? if so,
please state
a) Name of the insurer
b) The period of insurance
a)
b)
13. Has any insurer in respect of any professional
indemnity cover
a) Declined a proposal from the Proposer or from
the Proposer’s predecessors in business, or
b) Cancelled or declined to renew any policy, or
c) Demanded an increased rate, or
d) Required special terms to insure or grant any
renewal?
a)
b)
c)
d)
14. Amount of indemnity required
a) Any one event or series of events arising out of
any one cause.
b) All events during the period of insurance.
a)
b)
15. Period of Insurance From To
16. Does the Proposer wish to extend the policy to
cover
a) Dishonest, fraudulent, criminal or malicious
acts of employees in relation to the Proposer’s
Professional work
b) Loss of or damage to documents? [What will be
the greatest value at risk at any one time?]
if so,
i. State the amount to the insured under each
ii. Give details of any claim(s) or loss(es) under
the extension (s) required
a)
b)
i.
ii.
I / we hereby declare that the above statements and answers are true and compete and that no material
fact has been with-held, mis-stated or mis-represented and I / we agree that this proposal and
declaration shall be the basis of the contract between me/us and ------------------------------ whose
standard policy for the Insurance proposed is acceptable to me/us.
Place:
Date : Signature of the Proposer
(A partner / Director of the Firm / Company must sign this proposal form)
Note: The liability of the Company does not commence until the proposal has been accepted by the
Company and the premium paid.
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 on 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
prospectuses 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 five hundred rupees.
WHO CAN DERIVE BENEFITS FROM THIS COVER?
Professional Indemnity Insurance Policies are effected by professionals e.g. Solicitors, Accountants,
Doctors against liability to pay damage to their clients due to their negligence in the performance of
their professional duties.
WHAT IS THE COVER AVAILABLE?
The Company agrees to indemnify the insured against any claim for damages for breach of
professional duties which may be made against him during the currency of the Policy due to any
negligent act error or omission committed either by the insured or on behalf of the insured in their
Professional Capacity.
Exceptions of the Policy are:
a) Libel or Slander.
b) Loss of documents.
c) Consequential loss.
d) Losses suffered out of fraudulent act of employees.