Proposal form for
professional consultants

Please fill in the form below, and then click the submit button.

Business details

Name of business:

Address of business:

Email address:

Telephone number:

Date established:

Select the option that most accurately describes your general activities:

Are you a member of the British Computer Society:

Membership No:

Are you a member of the Institute of Interim Management:

Membership No:

Employers Reference/PAYE Number (ERN)** 

Not applicable:

Companies House Reference Number (CHRN)** 

Not applicable:

**Insurers who underwrite employers’ liability insurance are legally required to supply data regarding Employers Reference/PAYE Numbers to a centralised database known as the Employers’ Liability Database (ELD), so this information is required. CHRN is applicable to Ltd companies only.

Please provide the name, addresses, CHRN and ERN/PAYE of any subsidiary companies to be insured under the policy, please use a separate sheet and submit these with your proposal.

Details of Directors / Principals / Consultants of the business

Select the number of:

Practising Directors/Principals/Consultants

Other staff

NOTE:
If the amounts required exceed the maximum amount available, please
phone (020) 7444 0010 for a tailored quotation.

Please give the following details of the Directors/Principals/Consultants of the business:

 

Name

Relevant Qualifications / Experience

1.

2.

3.

4.

Other information about the business


Please provide a full and clear description of your business activities:

My annual turnover is : £

The business turnover averages more than £200,000 per director / principal / consultant per annum:

NOTE:
If the answer is "yes", please phone (020) 7444 0010 for a tailored quotation.

All policies will include £10,000,000 Employers' Liability cover when required by appropriate legislation. Please refer to the Description of Cover for this section and select whether or not required:

Please select amount of Professional Indemnity Required:

Note:
This section of cover is on a "claims made" basis please refer to the policy descriptions for further details

Please select amount of Public/Products Liability Required:

Note:
If the amount exceed the maximum amount available, phone (020) 7444 0010 for a tailored quotation.

Please select Period of Cover Required:

Confirmation

We can confirm that:

The Directors/Principals/Consultants, after enquiry, are NOT aware of or suspect or have grounds for suspecting any circumstances which might give rise to a claim against the business or any present or former Directors/Principals/Consultants.

NO claim such as would be covered by the proposed insurance has ever been made against the company or any of its Directors/Principals/Consultants whilst in this or any other company.

NO insurer has ever declined a proposal or renewal for this business or any Director/Principal/Consultant.

We have read and accept DKRI's terms of business

We have had an opportunity to consider the specimen policy wording available on this site.

After submitting this form you will be provided with a quotation. To proceed simply print off the quotation, sign the declaration and return it to us with your cheque for the premium and insurance tax due.

Upon receipt, cover will be issued and the appropriate Insurance confirmation will be sent to you. In the unlikely event that your proposal is not acceptable to Insurers your cheque will be returned immediately we receive it.

Please note that cover does not incept until your proposal form has been accepted by Insurers.