SURVEYORS - OBFSURVEYORS. PROFESSIONAL INDEMNITY ... company, partnership, limited liability...
Transcript of SURVEYORS - OBFSURVEYORS. PROFESSIONAL INDEMNITY ... company, partnership, limited liability...
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Coverholder at
OBF Insurance Group Ltd. is regulated by the Central Bank of Ireland. Registered in Ireland No. 39988. Brokers Ireland Member.
OBF Insurance Group Ltd. Bridge House, Baggot Street Bridge, Dublin 4. D04 X2P1T: +353 1 660 1033 / 676 0201 | F: +353 1 668 7985 | E: [email protected] | W: www.obf.ie
SURVEYORSPROFESSIONAL INDEMNITYPROPOSAL FORM
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Please Note:
• Thisisisaproposalforacontractofinsurance,inwhich‘proposer’or‘you/your’meanstheindividual,company, partnership, limited liability partnership, organisation or association proposing cover.
• ThisisaproposalformforapolicyrelatingtoclaimsmadeagainsttheInsuredduringtheperiodofthepolicy only – CLAIMS MADE.
• Pleaseanswerallthequestionsgivingfullandcompleteanswers.Pleaseuseaseparatesheetofpaperif there is insufficient space. If necessary please write additional relevant facts on a separate sheet of paper.
• Theproposalformmustbecompleted,signedanddatedbyapersonwhoisoflegalcapacityandhastheauthorisationtorequestthisinsurancefortheProposer.
• ThisformdoesnotbindtheProposerbutwillformpartoftheInsurancecontractiftakenup.
• Allmaterialfactsmustbedisclosed,asfailuretodosomayrenderanypolicyorcertificatevoidable,or severely prejudice your rights in the event of any claim. A material fact is one likely to influence acceptance or assessment of the proposal by Underwriters. If you are in doubt as to what constitutes a material fact, you should consult your broker.
Please supply the following additional information:
• CompanyBrochure
• CVsofPrincipals
• CopyofStandardContractTermsandConditions(ifapplicable)
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DETAILS OF THE PROPOSER
1. Name(s)(includingtradingnames/subsidiarycompanies)ofallentitiestobeInsured:
2. Main Address:
3. Website:
4. Email address:
5. Phone No: 6. Establishment Date of Firm
7. Please state total number of: Principals/Partners/Directors: Other Technical Staff:
QualifiedStaff: Administrative/Other:
8. a)DetailsofallDirectors/Partners/Principals:
Partners/Principals Qualifications Date QualifiedHow long a Director, Partner, Principal ofthis firm/company
9. a)HastheNameoftheProposereverbeenchanged? Yes No
b)Hasanyotherpracticeorbusinessamalgamatedormergedwithyou? Yes No
c)Haveyoupurchasedanyotherpracticeorbusiness? Yes No IfYes,pleaseprovidefulldetails:
10. IscoverrequiredforanyPartner’sLiabilitypriortojoiningthefirm? Yes No IfYes,pleaseprovideNameofPartner,NameofPreviousFirmandDateat whichthePartnerjoinedtheabovefirm:
11. If the Proposer is a sole practitioner, what procedures are in place for periods of absence from the office or illness?Pleaseprovidefulldetails:
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12. Please list the professional, regulatory bodies, trade associations or societies to which you belong:
13. Please give the name and experience of any person carrying out structural surveys and/or valuation Reports who is not a Fellow of Associate of the Royal Institute of Chartered Surveyors or a Fellow or Associate of the IncorporatedSocietyofValuersandAuctioneers,orRoyalInstituteofBritishArchitectsorFellowoftheFacultyofSurveyors(oritsequivalentinIreland):
14. a)Arewrittenreferencesobtainedinrespectofnewemployees? Yes No b)IsanyPartner/DirectororEmployeeallowedtosignchequesonhis/her signaturealone? Yes No
IfYes,uptowhatamount? €
c)HowoftenaretheentriesontheCashBookreconciledagainsttheBank Statementsbyaseniorperson,otherthantheheadbookkeeper?
d)Hastheproposereversustainedanylossthroughfraudordishonestyof anyemployee? Yes No
IfYes,pleaseprovidefulldetails:
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2. a)Pleaseprovideapercentagesplitofyourincomebygeographicalarea:
% of Gross Fees
DomesticContracts(Ireland)
UK Contracts
EU Contracts
USA/Canada(SubjecttononUSA/CanadaLaw)
USA/Canada(SubjecttoUSA/CanadaLaw)
Rest of the World Contracts
3. a)PleaseconfirmthepercentagesplitofyourincomebygeographicalareainIreland:
Area %
b)Ifother,pleasespecifyarea(s)/country(s)andcorrespondingpercentageofyourincome:
Area %
4. Whatpercentageofyourgrossfeeswasderivedinthepreviousfinancialyear fromyourlargestclient?
5. Pleaselisttheproposer’ssixlargestcontractsinthelastfiveyears:
Client Territory Description of Professional Services
Total Contract
Value
YourFees
Start Date
End Date
DETAILS OF ACTIVITIES/INCOME/FEES
1. a)Pleaseprovidethedetailsofyourgrossfees:
Last Financial Year Current Financial Year Estimate for Next Financial Year
Gross Fee
Maximum Fee
Average Fee
b)FinancialYearEnd:
/ // // /
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6. Pleaseprovideasplitofgrossfeesinthepreviousfinancialyear::
Activity %Quantity Surveying
Building Surveying
Land/Mineral/Hydrographic Surveying
ResidentialSurveys/ValuationsforLendingpurposes
OtherResidentialSurveys/Valuations
CommercialSurveys/ValuationsforLendingPurposes
OtherCommercialSurveys/Valuations
Planning & Development Consultancy
ProjectCo-Ordination(whereyouhaveNoresponsibilityforappointmentofotherconsultants/contractors)
ProjectManagement(whereyouhaveresponsibilityforappointmentofotherconsultants/contractors)
Architectural
Environmental
Residential Property Management
Commercial Property/Land Management
Rent Reviews/Lease Renewals
Residential Estate Agency
Commercial Estate Agency
Auctioneering – Livestock
Auctioneering – Other
Building Society Agency
General Insurance Business
Financial Services
Loss Assessing and Adjusting
Other Work – Please provide full details on a separate sheet
TOTAL 100%
7. If you have ceased to provide any of the services detailed in Question 6 above in the last three years, please confirmthenatureofservicesprovidedandthefeesderivedfromthisactivity(ies):
8. Please provide further information about the work you have undertaken in the past for the following activities: a)QuantitySurveying:
Averagetotalcontractvalueinthelast3years: €
Highesttotalindividualcontractvalueinthelast3years: €
b)ResidentialSurveys/ValuationsforLendingPurposes.Forthelast3yearspleaseconfirm:
Average annual number of reports
Highestsinglepropertyvaluation: €
AverageValuation: €
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Please identify your 3 largest clients:
Name Annual Fee Income - €
c)CommercialSurveys/ValuationsforLendingPurposes:
Average annual no. of reports
Highestsinglepropertyvaluation: €
Highestsinglepropertyvaluation: €
AverageValuation: €
Please identify your 3 largest clients:
Name Annual Fee Income - €
d)OtherCommercialSurveys/Valuations:
For the last 3 years please provide details of your 3 largest valuations:
Valuation Client Purpose
e)ProjectCo-Ordination: Pleaseconfirmthehighesttotalindividualcontractvalueinthepast3years: €
f )ProjectManagement: Pleaseconfirmthehighesttotalindividualcontractvalueinthepast3years: €
g)ArchitecturalWork: Please provide details of the 3 largest contracts where construction commended during the last 3 years:
Description Extent of Service (full etc.)Total
Contract ValueApprox.
Completion Date
h)Environmental: Please provide a full description of your activities:
Do you undertake any work which involves polluted or contaminated land or property, or advise third parties as to whether or not land or property may be pollutedorcontaminated? Yes No
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IfYes,doyouhaveastandardcontractortermsofengagementwhichincorporates adisclaimerorlimitationofliabilityinrespectofpollutionandcontamination? Yes No
IfYes,pleaseconfirmhowlongthishasbeenused: (Pleaseattachacopy)
i)CommercialProperty/LandManagement(incRentReviewsetc.): Isthereaworkingdiarysystemwhichischeckedregularly? Yes No
j)CommercialEstateAgency: Averageindividualpropertyvaluehandledinthelast3years? €
Highestindividualpropertyvaluehandledinthelast3years? €
k)Auctioneering: Forthelastyearpleaseconfirmthefollowing:
Fees - € Max Value - € Ave Value - €
Livestock & Deadstock
FineArtorAntiques
Property or Land
Other – Please provide details on a separate sheet
l)FinancialServices: DoyouundertakeanyFinancialServicesactivities? Yes No
Areyoutied(forthepurposesoftheFinancialServicesAct)toanyorganisation? Yes No
Ifindependent,howareyouregulated?
m)OtherWork: Please provide full details of any other work you undertake:
9. FORSURVEYANDVALUATIONWORKONLY–IfNONEpleasemarkasN/A N/A
a)Arevaluationsonlyundertakenbyqualifiedvaluers? Yes No b)PleaseconfirmwhoundertakestheSurveys/Valuationsandtheirqualifications (whereapplicable):
c)Doyouhaveanysysteminplaceforthecross-referencingofvaluationsfor similarproperties? Yes No
IfYes,howlonghasthissystembeeninoperation?
IfNo,howwouldyousupporttheaccuracyofanyvaluation?
d)HaveyouatalltimescompliedwiththeRICSManualofValuationGuidance NotesandtheStatementofAssetValuationPracticeandGuidanceNotesand, whenissued,theAppraisalandValuationManual? Yes No
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If No, please explain:
10. Doyouuseastandardformofcontract,agreementorletterofappointment? Yes No IfYes,pleaseattachacopy
11. Doyoualwaysconfirmverbalreportsinwriting? Yes No If No, please explain:
12. Do you undertake any work which involves polluted land or property or advise third partiesastowhetherornotlandorpropertymaybepollutedorcontaminated? Yes No
IfYes,doyouhaveastandardcontractortermsofengagementwhichincorporates adisclaimerorlimitationofliabilityinrespectofpollutionorcontamination? Yes No
IfYes,pleaseconfirmhowlongthishasbeenusedandattachacopy:
13. a)Doyouusetheservicesofconsultants,sub-contractorsoragents? Yes No
IfYes,doyourequirethemtocarrytheirownPIInsurance? Yes No
IfYes,towhatlimit?
b)Whatpercentageofyourincomerelatestosub-contractedwork?
14. a)DoesthePrincipals/Partners/Directorsoftheproposerhaveanyassociation withorfinancialinterestinanyotherpractice,companyororganisation? Yes No
IfYes,pleaseprovidefulldetails:
b)Is,orhastheproposerbeenamemberofaconsortium,grouppractice,jointventure,strategicallianceorinvolvedinanysingleprojectpartnership?IfYes,pleaseprovidefulldetails:
NB: Special arrangements must be made with insurers if indemnity is to be granted.
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PREVIOUS/CURRENT INSURANCE
1. DoestheProposercurrentlyhaveaProfessionalIndemnityInsurancepolicyinforce?Yes No
IfYes:
a)Insurer
b)ExpiryDate
c)LimitofIndemnity d)Excess
e)Premium
f )ExpiryRetroactiveDate
2. Has any previous policy for Professional Indemnity insurance been cancelled orrefusedorhadanyspecialtermsimposedbyanyinsurer? Yes No
IfYes,pleaseprovidefulldetails:
CLAIMS/CIRCUMSTANCES INFORMATION1. Haveanyclaimsallegingnegligentact,errororomission(successfulorotherwise) been made against you, your predecessors in business, or present or past partners, principalsordirectors? Yes No
IfYes,havesuchmattersbeennotifiedtocurrentorpreviousUnderwriters? Yes No
Please provide full details:
3. PleaseindicatetheLimitofIndemnityrequired:
€500,000 €1,000,000 €1,500,000 €2,000,000 €2,500,000
€3,000,000 €5,000,000
Please specify if other:
4. WhatExcessistheProposerpreparedtocarryuninsured?
€1,000,€2,500,€5,000,€10,000or‘Other’
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DATA PROTECTION
OBF Insurance Group Ltd. recognise that protecting personal information including sensitive personal information is very important and we recognise that you have an interest in how we collect, use and share such information. Our DataProtectionPolicyisinlinewiththerequirementsundertheGeneralDataProtectionRegulations(GDPR)whichare effective from 25 May 2018.
Please read the following carefully as it contains important information relating to the information that you give us or has been provided to us on your behalf. If you provide information relating to anyone other than yourself, you are responsible for obtaining their consent to the use of their data in the manner outlined below.
Full details of how we collect, use, store and protect your data can be found in our Data Privacy Notice, a copy of whichisavailableonrequestorviaourwebsite,www.obf.ie.
What does OBF Insurance Group Ltd. do with your personal data?
Information you provide will be used by OBF Insurance Group Ltd. for the purposes of processing your application and administering your insurance policy. OBF Insurance Group Ltd. may need to collect sensitive personal data relating to you(suchasmedicalorhealthrecords)inordertoprocessyourapplicationand/oranyclaimmade.
AllinformationsuppliedbyyouwillbetreatedinconfidencebyOBFInsuranceGroupLtd.andwillnotbedisclosedto any thirdparties except (a) toour agents, sub–contractors and reinsurers (b) to thirdparties involved in theassessment,administrationorinvestigationofaclaim(c)whereyourconsenthasbeenreceivedor(d)tomeetourlegal or regulatory obligations. In order to provide you with products and services this information will be held in the data systems of OBF Insurance Group Ltd. or our agents or subcontractors. The data is held on servers with multiple layers of security. Please note that some servers which may hold your data are located outside the EU.
We will hold data collected from you for the duration of our business relationship with you and for six years after that.ThisisarequirementundertheCentralBank’sConsumerProtectionCode2012.Yourdatamaybeusedforthepurposesofautomateddecisionmakingbutwillnotbeusedforprofilingpurposes.
OBF Insurance Group Ltd. may pass your information to other companies for processing on its behalf. OBF Insurance Group Ltd. will ensure that its transfer of data is lawful and that your information is kept securely and only used for the purpose for which it was provided.
CallstoandfromOBFInsuranceGroupLtd.arerecordedforqualityassuranceorverificationpurposes.
2. Areyouoranypartners,directorsorprincipals,afterhavingmadefullenquires,includingofallstaff,awareofany of the following matters
a)Anycircumstanceswhichmaygiverisetoaclaimagainstyou,yourpredecessors inbusinessoranypastorpresentpartner,directorprincipaloremployees? Yes No
b)Thereceiptofanycomplaints,whetheroralorinwriting,regardingservices performedoradvicegivenbyyou? Yes No
IfYes,pleaseprovidefulldetails:
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Your Rights under our Data Protection Policy
Youhavetherightto:
• Accessthedataweholdaboutyou• Havethedataweholdaboutyoutransferredtoanotherpersonororganisation• Haveinaccuratedataaboutyoucorrected• Haveinformationaboutyouerased(thiscouldaffectourabilitytoprocessyourbusiness)• Objecttodirectmarketingfromus• Restricttheprocessingofyourdata(thiscouldaffectourabilitytoprocessyourbusiness)• Makeacomplainttousabouttheimplementationofourdataprotectionpolicyandprocedures.
Toaccessthedataweholdaboutyou,youwillneedtocompleteandsubmitaDataAccessRequestForm,availableonrequestorviaourwebsite.
Data Breaches
In the event of a data breach which results in your personal data being compromised, we will advise the Data Protection Commissioner within 72 hours at most, unless the data was encrypted or anonymised. Were there is a high risk to your rights, as set out in the GDPR, we will also advise you of the details of the breach and the steps we have taken to rectify it and prevent its recurrence.
Fraud Prevention, Detection and Claims History
In order to prevent and detect fraud and the non-disclosure of relevant information OBF Insurance Group Ltd. may at any time:
• ShareinformationaboutyouwithcompaniesororganisationsoutsideOBFInsuranceGroupLtd.includingwhere applicable private investigators and public bodies including An Garda Siochana;
• Checkand/orfileyourdetailswithfraudpreventionagenciesanddatabasessuchasInsuranceLink,andifyougive us false or inaccurate information and we suspect fraud, we will record this. For more information on the functioning of InsuranceLink, please visit insurancelink.ie.
OBF Insurance Group Ltd. may also search these agencies and databases to :
• Helpmake decisions about the provision and administration of insurance, credit and related services for you and members of your household;
• Tracedebtorsorbeneficiaries,recoverdebt,preventfraudandtomanageyouraccountorinsurancepolicies;• Checkyouridentitytopreventmoneylaundering,unlessyoufurnishuswithothersatisfactoryproofofidentity;• Undertake credit searches and additional fraud searches.
DECLARATION
The undersigned authorised Person declares that the statement and particulars in this Proposal form are true and thatnomaterialfactshavebeenmisstatedorsuppressedafterenquiry.Theundersignedagreesthatshouldanyofthe information alter between the date of this Proposal and inception date of the insurance to which this proposal relates, they will give immediate notice thereof. The undersigned agrees that this Proposal, together with any other information supplied by us shall form the basis of any contract of insurance effected thereon.
Signature:
Name:
Position: Date:
1 Names including trading namessubsidiary companies of all entities to be Insured: 2 Main Address: 3 Website: 4 Email address: 5 Phone No: 6 Establishment Date of Firm: PrincipalsPartnersDirectors: Other Technical Staff: Qualified Staff: AdministrativeOther: If Yes please provide full details: which the Partner joined the above firm: illness Please provide full details: 12 Please list the professional regulatory bodies trade associations or societies to which you belong: of Surveyors or its equivalent in Ireland: €: undefined: If Yes please provide full details_2: b Financial Year End: Domestic Contracts Ireland: UK Contracts: EU Contracts: USACanada Subject to non USACanada Law: USACanada Subject to USACanada Law: Rest of the World Contracts: undefined_3: Quantity Surveying: Building Surveying: LandMineralHydrographic Surveying: Residential SurveysValuations for Lending purposes: Other Residential SurveysValuations: Commercial SurveysValuations for Lending Purposes: Other Commercial SurveysValuations: Planning Development Consultancy: Project CoOrdination where you have No responsibility for appointment of other consultantscontractors: Project Management where you have responsibility for appointment of other consultantscontractors: Architectural: Environmental: Residential Property Management: Commercial PropertyLand Management: Rent ReviewsLease Renewals: Residential Estate Agency: Commercial Estate Agency: Auctioneering Livestock: Auctioneering Other: Building Society Agency: General Insurance Business: Financial Services: Loss Assessing and Adjusting: Other Work Please provide full details on a separate sheet: confirm the nature of services provided and the fees derived from this activityies: €_2: €_3: undefined_4: €_4: €_5: undefined_5: €_6: €_7: €_8: €_9: €_10: Please provide a full description of your activities: undefined_6: €_11: €_12: If independent how are you regulated: Please provide full details of any other work you undertake: where applicable: undefined_7: If No how would you support the accuracy of any valuation: If No please explain: If No please explain_2: If Yes please confirm how long this has been used and attach a copy: undefined_8: undefined_9: If Yes please provide full details_3: involved in any single project partnership If Yes please provide full details: undefined_10: undefined_11: undefined_12: undefined_13: undefined_14: f Expiry Retroactive Date: undefined_15: Please specify if other: €1000 €2500 €5000 €10000 or Other: Please provide full details: If Yes please provide full details_4: Name: Position: Date: Text-1: 0: 1: 2: 3: 4:
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