Proposal Form

Professional Indemnity Insurance for Surveyors

Please complete, sign and return together with the attachments to:

LLP 273 - Jul 12

If you have any questions regarding this form, please contact us either on the telephone number above or by visiting the CONTACT US section at www.locktonaffinity.co.uk/surveyors

Lockton Affinity A Division of Lockton Companies LLP The St Botolph Building 138 Houndsditch London EC3A 7AG Telephone: 0845 050 0262 Email: surveyors@uk.lockton.com

Important notes regarding the completion of this proposal form.

1. Disclosure

Any “material fact” must be disclosed to insurers - A “material fact” is any information which may influence the judgement of a prudent insurer in deciding whether to accept the risk and if so, on what terms.

Any “material change” must be disclosed to insurers. - A “material change” is any material fact which arises on renewal or during the currency of the policy that has not previously been disclosed as a material fact. Examples of material changes to material facts include:

· Fraud on the part of any of the Partners and Employees

· A change in the composition of the firm's practice

· Mergers and Acquisitions of other firms

· Conversion to a Limited Liability Partnership

If you are unsure whether a fact or change is material or not, you should disclose it. Failure to provide all “material facts” and/or notify all “material changes” may cause the contract of insurance to be void from inception i.e. your insurers will return the premium and there will be no cover for any claims made under the policy. 2. Presentation

This proposal form must be completed in ink by an authorised individual or principal of the firm.

All questions must be answered.

If there is insufficient space to provide answers, additional information should be provided on the firm's headed paper.

Where available brochures, standard contract conditions, agreements and letters of appointment should be provided.

Failure to present insurers with information in an appropriate manner may adversely influence the ability of insurers to offer terms.

3. Guidance

If in doubt as to the meaning of any question contained within this proposal form or the issues raised in (1)or (2) above, please contact an account executive at Lockton.

LLP 273 - Jul 12

Affinity A division of Lockton Companies LLP Authorised and regulated by the Financial Services Authority A Lloyd's Broker www.locktonaffinity.co.uk/surveyors

Percentage of total feesAddresses

Additional information should be provided on separate sheets (on your headed notepaper), clearly identifiable as forming part of the proposal form.

Please ensure that all relevant sections of the Proposal are completed.

a) Name(s) under which business is conducted including previous trading names: (‘Firm/Individual’)

1.

2.

Website:Tel No:

Addresses of all offices & percentage of total fees in each.

Date commenced:3.

4. Give details below of all Principals (including details of sole principal).

5.

QualificationsAgeNo. of years in this capacity with the

ProposerName Date Qualified

Do you require any consultants or former consultants to be covered for work they undertake for and on behalf of your business? If `YES', please provide details as follows:

a)NoYes

Date QualifiedQualificationName

State number of permanent staff6.

i) Full Time:a) Qualified ii) Part Time: i) Full Time:b) All others ii) Part Time:

Has the Firm/Individual any other Professional Indemnity insurance in force? NoYes7.

a) Please indicate Limit of Indemnity required:8.

Other £1,000,000£500,000£250,000 (please specify) £

Is cover required for Principals’ Previous Business with another firm in respect of any principal named in 4?9.

If “Yes” please supply details including: name of principal, name of previous firm, period as a principal, profession of firm, activities performed and fee income of the principal’s previous firm.

NoYes

b) What is the firm's procedure to ensure supervision of self employed consultants?

£2,000,000 £5,000,000

Insurer Policy Period Limit of Indemnity Excess Premium Fees Broker

Please completed the following information about your firm's professional insurances for the previous 5 years.

b) Have you ever been declined professional indemnity insurance and referred to the Assigned Risk Pool? NoYes

a. State gross fees (including those paid to sub-contractors) payable by clients for work undertaken.

i) in the UK (excluding c. and e. below)

ii) in the USA, its territories and possessions and Canada

iii) in the UK and elsewhere (excluding USA and Canada) for clients domiciled in the USA, its territories and possessions or Canada, including work for USA companies, subsidiaries of USA companies or USA subsidiaries of companies based elsewhere

iv) Elsewhere (excluding USA and Canada)

v) In the UK for clients domiciled elsewhere* (excluding USA and Canada)Total of i), ii), iii), iv) and v) above

Last CompletedPrevious Current (estimate)

£ £ £

10.

£ £ £

£ £ £

£ £ £

£ £ £

Financial Year end (dd/mm/yy)

£ £ £

b. Is the practice represented in any way in the USA or its territories and possessions, or Canada? NoYes

If ‘Yes’, give details.

Last Completed

c) State largest fee earned from any client

Previous Current (estimate)

£ £ £

Last Completed

State the approximate percentage of last year’s gross fees and of the fees estimated for the forthcoming year (including those paid to sub-contractors) payable in respect of:

11.

a) Agricultural consulting

d) Auctioneering

h) Clerk of works

g) CDM co-ordination (formerly planning supervision)

%

%

%

%

% %

% %

Current (estimate)

Last completed

Financial Year end (dd/mm/yy)

(Please specify type of work)

b) Architectural design & planning work % %

c) Asbestos inspections (separate questionnaire will be required) % %

f) Cartographical surveys

e) Building surveying % %

% %

(Please specify type of work)

i) Council tax rating

l) Estate agency

ii) commercial

iii) development agency

iv) property investment

i) residential

v) other, (Please specify type of work):

m) Estate appraisal

n) Expert witness

k) Energy assessment

ii) commercial

i) residential

j) Employers agent

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

i) general insurance intermediaryo) Financial services

ii) mortgage broking

iii) building society agency

iv) pensions and investments

v) other, (Please specify ):

% %

% %

% %

% %

% %

d) State gross fee paid to contractors/sub-consultants £ £ £

i) hydrographic surveyingp) Land surveying

ii) mineral surveying

iii) setting out

iv) Other (please specify)

% %

% %

% %

% %

q) Leasehold enfrancisement

t) Party walls, schedules of dilapidation, specification & supervision of repairs, redecoration & refurbishment

u) Project co-ordination* (please complete Construction Questionnaire)

v) Project management* (please complete Construction Questionnaire)

w) Property management

ii) residential lettings

iii) residential rent reviews

iv) commercial property management (excluding rent reviews & asset management

i) residential property management (excluding lettings and rent reviews)

v) commercial rent reviews

vi) commercial asset management***

s) Marine -

Current (estimated)

Last completed

x) Quantity surveying (excluding project co-ordination/management) (please complete Construction Questionnaire)

aa) Town planning

ab) All other work

z) Surveying and valuing (not specified elsewhere above)

ii) commercial** (please complete S & V Questionnaire)

i) residential** (please complete S & V Questionnaire)

100% 100%* Declare fees under Project Management where the Proposer is responsible for appointing other consultants or contractors in connection with the project works and declare under Project Co-ordination where the Proposer’s principal makes such appointments. ** Residential / commercial refers to the end use / purpose of the property being inspected or valued. *** Commercial asset managers ensure the best investment or return on a portfolio of properties including the disposal or acquisition of properties.

r) Loss assessing/Adjusting

y) Ratings

Please specify type of work:

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

% %

a) If fees are received in connection with general insurance Intermediary, indicate FSA status, i.e. FSA authorised, Appointed Representative, Introducer Appointed Representative or other (explain below).

12.

b) If fees are declared under 14ab) All other work, give details of the type of work undertaken in the box below.

Please provide an approximate split of the geographical spread of the practice’s work in the following categories.

%

Elsewhere

%

%

Remainder of London and South East England

%

%

Central London & Docklands

%

Property Management

Surveying & Valuing

13.

Company Start/finish dates Contract value Fee Contract Type Service provided

Details of the five largest contracts undertaken in the last five years.

CONTRACT SIZE15.

Is the Firm/Individual able to confirm that :

16.

NoYes

NoYes

NoYes

NoYes

NoYes

c) Work undertaken by staff is regularly reviewed/audited by a principal or qualified manager?

d) No disciplinary action has been taken by any outside professional or regulatory body against any Principal or member of staff?

e) Written procedures or checklists are used for the professional services provided?

f) Contracts or terms of acceptance are evidenced in writing, specify the work to be undertaken and the extent of the Firm/Individual’s responsibility and always drafted by legal professionals or vetted by legal advisors?

g) Records are kept of all on-site visits, contracts, letters of engagement, client meetings and telephone calls?

h) Working papers, including survey and valuation files, are retained for at least 6 years? NoYes

NoYesi) Diary systems, registers or other procedures are in operation to ensure that deadlines (including those relating to rent reviews) are met?

j) A formal review of working procedures is undertaken at least annually? NoYes

NoYesk) Satisfactory written references are always obtained for new employees and Principals?

a) Are all offices under the supervision of a principal and are there arrangements in place in the event that they are absent? NoYes

b) Do all employees devote all of their time to the firm? If not then please provide details. (Or something to this effect - mainly aimed at sole practitioners).

NoYes

If 'NO' to any of the above, give details below.

SUBCONTRACTORS14.

NoYes

NoYes

a) Do you utilise subcontractors?

b) What percentage of your fees are subcontracted?

c) Do you ensure that subcontractors carry their own PII?

d) What is the selection process for subcontractors?

e) What is the nature of the work that is subcontracted?

QUALITY AND RISK MANAGEMENT

17. Please provide details of:

Life Long Learning/Continuous Professional Development

Please provide information on how the practice ensures that all staff and principals maintain their qualifications and ensure their knowledge is up-to-date.

18. a) Is the Proposer accredited to or in the process of becoming accredited to an ISO 9000 Quality Management System or subject to any other form of external assessment?

NoYes

b) Does the Proposer subscribe to a professional code of practice? If ‘Yes’, in either case please give details below.

NoYes

OTHER INSURANCES

Please confirm if your practice maintains the following insurances:

Yes NoOffice contents, Employers/Public Liability insurance

Directors & Officers Yes No

If 'Yes', please confirm renewal date

If 'Yes', please confirm renewal date

Yes No If 'Yes', please confirm renewal dateEmployment Practices Liability

19.

FIDELITY20.

NoYes

If 'YES' in either case, please give details below:

Has any insurer, in respect of the risks to which this proposal relates, ever:

a) Has the proposer suffered any loss during the past 10 years through fraud or dishonesty of any partner or employee? If yes then please give details regarding the date, circumstances, amount of loss and steps taken to prevent a repeat offence.

NoYesc) Is any cheque or bank instrument ever signed without one of the signatories having examined the supporting documentation?

b) Do all cheques or other bank instruments drawn for more than £25'000 require at least two manually applied signatures to be added after the amount has been inserted?

NoYes

NoYese) Are employees receiving cash or cheques in the course of their duties required to remit all monies received, or bank in full on the day of receipt or the next banking day?

d) Are bank statements, receipts, counterfoils and supporting documents checked at least monthly against cash book entries and the balance tested with cash and unpresented cheques independently of any partners or employees usually responsible at least monthly?

NoYes

NoYesg) Can you confirm that no one individual is permitted to release computer initiated transfer authorities to the bank and that a second person of at least the same authority is required to check prior to release of the instructions?

f) Is cash in hand checked independently of any employees usually responsible at least monthly and without warning? NoYes

21. CLAIMS

Has any claim been made against the Firm/Individual or any principal, consultant or employee or predecessor firms during the last ten years in respect of the risks to which this proposal relates? If 'YES' give details (by separate note if preferred)

NoYes

Brief detail of each claim Estimated outstanding cost

Date of claim Cost (if any) of claim paid

What action has been taken to prevent a recurrence of the situation which gave rise to each claim?22.

Is any principal, consultant or employee, after enquiry, aware of any circumstances which might:23.

NoYes

NoYes

NoYes

a) give rise to a claim against the Firm/Individual or any predecessors in business or any of the present or former principals?

b) result in the Firm/Individual or any predecessors in business or any of the present or former principals incurring any losses or expenses which might be within the terms of this cover?

c) otherwise affect the Company’s consideration of this insurance?

If 'YES' give details including maximum potential cost (by separate note if preferred)

ADDITIONAL INFORMATION Use this space to provide further information in support of answers given to questions in this Proposal.

Please state question number clearly.

PLEASE SIGN THE DECLARATION ON THE NEXT PAGE

Data Protection

By signing this proposal form you consent to Lockton Companies LLP using the information we may hold about you for the purpose of providing insurance and handling claims, if any, and to process sensitive personal data about you where this is necessary (for example criminal convictions). This may mean we have to give some details to third parties involved in providing insurance cover. These may include insurance carriers, third-party claims adjusters, fraud detection and prevention services, reinsurance companies and insurance regulatory authorities. In the course of performing our obligation to you, this information may be disclosed to agents and service providers appointed by us and insurers (which includes their re-insurers, legal advisers, loss adjustors or agents). Where such sensitive personal information relates to anyone other than you, you must obtain the explicit consent of the person to whom the information relates both to the disclosure of such information to us and its use by us as set out above. The information provided will be treated in confidence and, where appropriate, in compliance with the relevant Data Protection legislation. You have the right to apply for a copy of your information (for which we may charge a small fee) and to have any inaccuracies corrected.

From time to time, we may disclose personal information (other than sensitive personal data) to other Lockton Companies. We or they may use that information to advise you of our services which may be of interest to you.

If you would prefer not to receive information, please tick this box I/We confirm that we agree to receiving email communication from Lockton NoYes

I/We declare that the above statements and particulars are true, full enquiry having been made, and I/We have not omitted, suppressed or mis-stated any material facts which may be relevant to insurer's consideration of this proposal form and undertake to inform the Insurer of any change to any material fact that occurs prior to the point at which the insurance contract has been agreed. I/We understand that the information I/We provide will be used in deciding the price charged by the Insurer for the risk and whether the Insurer will accept the application and the terms of any policy provided. I/We hereby consent to the use and disclosure of information including personal data for the purposes of and as set out in the above paragraph entitled “Data Protection”.

Declaration

Print Name:

Date:

On Behalf of :

Signature:

(an authorised individual/partner/principal/director)

Please note, if you wish to submit your form via email, an indication of terms and conditions may be provided on the basis of this proposal questionnaire. An original signature is required before a contract of insurance can be made. Encrypted signatures are not acceptable.

Signing this form does not bind the Practice to complete the insurance. We recommend that you keep a record of all information supplied to us, including copies of letters and this proposal form, for the purpose of entering into this contract.