Professional Indemnity Insurance Proposal Form …

1 Professional Indemnity Insurance Proposal form For The Design and Consulting Departments of Contractors Important Notice 1. This is a Proposal for a contract of Insurance , in which Proposer or you/your means the individual, company, partnership, limited liability partnership, organisation or association proposing cover. 2. This Proposal must be completed in ink, signed and dated. All questions must be answered to enable a quotation to be given but completion does not bind you or Underwriters to enter into any contract of Insurance . If space is insufficient to answer any questions fully, please attach a signed continuation sheet.

2 You should retain a copy of the completed Proposal (and of any other supporting information) for future reference. 3. All facts material to the proposed Insurance must be disclosed, fully and truthfully to the best of your knowledge and belief. Failure to do so may make the contract of Insurance voidable or severely prejudice your rights in the event of a claim. A material fact is one likely to influence Underwriters assessment or acceptance of the Proposal ; if you are uncertain what may be a material fact, you should consult your broker. 4. You are recommended to request a specimen copy of the proposed policy wording from your Insurance broker and to consider carefully the terms, conditions, limitations and exclusions applicable to the cover.

3 1. General Information Name of Practice/Company. Address of registered office and/or principal place(s) of business (if different). Is cover being sought for any previous or subsidiary practices/companies? If so, please list on a separate signed sheet and provide full details including name, country of registration, address of principal place of business and ownership/relationship with the main practice. State the date when the main practice (and any other subsidiary practices/companies requiring cover), began and (where appropriate) ceased business? Markel Design & Construction Proposal form Page 2 Is the Practice financially associated with any other firms?

4 Yes No (If Yes , please provide full details.) During the past five years, has the name of the Practice been changed or has any other business been purchased or any merger or consolidation taken place? Yes No (If Yes , please provide full details.) 2. The Design and Consulting Department Staff Details Individual Details. Name of Principals and Senior Members of Staff Qualifications Date Joined Title of Positions Length of time in Position Numbers of Staff. Based in the Overseas Based Principals and Senior Qualified Members as listed Other Technical and Qualified Staff Clerical, Typists, Others TOTALS Do you use independent specialist consultants?

5 Yes No (If Yes , please provide full details.) Do you verify that they carry their own Insurance Yes No Are any persons ever hired from outside agencies on a short-term basis ? Yes No (If Yes , please provide full details.) Markel Design & Construction Proposal form Page 3 3. Work Undertaken Please give an approximate percentage split of the disciplines within your Design and Consulting Department. Architectural % Chemical Engineering % Soil Engineering % Structural Engineering % Nuclear Engineering % Mechanical Engineering % Surveying (i) Land % Electrical Engineering % (ii) Quantity % Planning Supervisor % (iii) Building % Cladding/Roofing % Foundations/Underpinning % Civil Engineering % Heating and Ventilating Engineering % Indicate as a percentage of total work the extent of the following activities.

6 (a) HOME BUILDING Design Only Design and Construct Power Plants Refineries and Petro Chemical Installations Manufacturing Plants Industrial Buildings Systems (b) ENGINEERING CONSTRUCTION Design Only Design and Construct Highways Bridges, Tunnels and Dams Railways, Airports, Harbours and Jetties Sewage/Water Schemes (c) INDUSTRIAL Design Only Design and Construct Power Plants Refineries and Petro Chemical Installation Manufacturing Plants Industrial Buildings Systems Markel Design & Construction Proposal form Page 4 (d) AMENITIES Design Only Design and Construct Hospitals and Nursing Homes Schools and Universities Hotels and Recreation Centres Do you engage in the manufacture or fabrication of any pre-engineered unit?

7 Yes No (If Yes , please provide full details.) Add here a statement of the type of work normally carried out, whether consisting of well-established techniques or of the nature of new and original thought developments, processes or designs employed. State whether and what licensing or similar agreements are in force and the degree to which supervision of them is exercised by associates. Have you ever failed to complete a project? Yes No (If Yes , please explain reason and type of project etc.) 4. Fees and Contracts Please give details of turnover. Past Financial Year Year ending Current Financial Year Year ending.

8 /../../../.. Home Overseas Home Overseas (a) Turnover where the practice designs and constructs from their own design and provides full technical supervision (b) Fees of those departments where the practice provides: (i) Design and Technical Services where no construction is involved by the practice (ii) Planning Supervisor Services as defined by the Construction (Design and Management) Regulations 1994. (a) Turnover where practice constructs from designs accepted on behalf of the practice by independent, qualified and insured consultants. (b) Turnover where Practice constructs from design and technical supervision accepted on behalf of the Practice by independent, qualified and insured consultants.

9 (c) Other turnover not mentioned above. Please provide brief details below. TOTAL TURNOVER FOR WHOLE PRACTICE Markel Design & Construction Proposal form Page 5 Please give details of the five largest contracts commenced during the last five years where the Design and Consulting Department has been involved. Date Started Name and Type of Project Services Performed Total Contract Value Estimated Date of Completion Please give details of any major new operations being undertaken during the next twelve months. 5. Business Associations and Qualifications Is the work of all Associated and/or subsidiary companies design departments/sections checked by Head Office?

10 Yes No (If No , please provide full details) (a) Is the Practice or any principal a member of a consortium or joint venture? Yes No (b) Has the Practice or any principal previously been a member of a consortium or joint venture ? Yes No If the answer to (a) and/or (b) is "Yes", special arrangements must be made with the Insurers. Please provide the relevant dates and the names of the other members and their respective capacities in the consortium or joint venture on a separate letterheaded sheet, together with copies of any contracts or agreements. Has the Practice a Quality Assurance System in place? Yes No (If Yes , please provide a copy of your certificate) Has the Practice or any partner, principal or director or any other company or organisation related to the Practice ever provided services in connection with the identification of asbestos, chemicals or other hazardous materials?