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MISCELLANEOUSPROFESSIONAL INDEMNITY PROPOSAL FORM

1) Full Name of Firm / Organisation

2) Date of Commencement of Firm :

3) Address(es) - (include all branches) :

4) Give a full description of the Firm's activities : -

5) Please categorise the activities of the Firm and indicate the approximatepercentage of the gross income/fees this represents : -

Category %

Total

100%

6. Names in full of all Partners, Principals or Directors : -

Name Qualifications Date obtained How longPrincipal ofthis Practice

a) If any of the above have less than 5 years practical experience in this type ofoccupation please provide curriculum vitae.

b) If Sole Partner, Principal or Directors, is this apart-time occupation? Yes/No

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c) Is this Firm or any Partner, Principal or Directorconnected or associated (financially or otherwise)with any other practice, Company or organisation? Yes/No

If yes, please give details

................................................................................................................................

................................................................................................................................

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d) Number of Staff : -

Professionally qualified

Others

Typists and Office Juniors

Consultants undertaking work on your behalf

Total

7. a) Please detail gross income/fees

Past FinancialYear

Current FinancialYear

Estimate ComingFinancial Year

Home Operations

Overseas Operations

In the case of Overseas operations please list countries involved and state whichjurisdiction applies.

b) Please state date of your financial year.

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8) Please list your five largest projects : -

Project Client Value Commenced Finished

9) Is any work Sub-Contracted?Yes/No

If yes, please give : -

a) Brief details (on Headed Paper) of Sub-Contracted Work

b) Are Sub-Contractors required to carry insurance to covertheir liability for such work? Yes/No

c) What is the limit of indemnity provided by that insurance?

10) Does the Firm enter into any written Agreement or operateunder any published conditions of engagement or letter ofappointment? If yes, please enclose. Yes/No

11) Please give the following : -

a) Name of current Insurers ___________________________

b) Total Limit of Indemnity ___________________________

c) Applicable excess ___________________________

d) Expiry date ___________________________

N.B. If not currently insured, please give details relative to the latest year thatinsurance was carried.

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I/We declare that the statements and particulars contained within this Proposal are trueand that I/We have not mis-stated or suppressed any material facts.

I/We agree that this Proposal together with any other information supplied by me/usshall form the basis of any Contract of Insurance effect thereon.

I/We undertake to inform Underwriters of any materials alteration to these factsoccurring before completion of the Contract of Insurance.

If you are in any doubt whether a Fact may affect the judgment of Underwriters youshould declare it, as failure to do so could invalidate the Insurance.

Signing this Proposal Form does not bind the Proposer or Underwriters to complete thisContract of Insurance.

_________________________ day of ______________________ 20 ________

Signature of Partner, Principal or Director _______________________________