Accountant Proposal Form - Direct Insurance …...2019/01/18 · Accountant Proposal Form 5 / 14 6....

Accountant Proposal Form

www.dilm.co.uk

Accountant Proposal Form 2 / 14

Instructions This Proposal form and all materials submitted shall be held in confidence. All questions must be fully answered and all requested information and/or required attachments submitted to enable a quotation or indication to be given. However, the completion and submission of this form does not bind the applicant or underwriters to enter into any contract of insurance. If a question does not apply, please write “N/A”. If the answer is none, state “none” or “0”. If more space is needed, please continue on a separate sheet of the applicant’s letterhead and indicate the question number to which the information responds. This Proposal form and any separate continuation sheets must be completed, signed and dated by a principal of the business.

1) Names(s) of Firm(s)

Names(s) of Firm(s) Commencement date

£

£

Website address:

Address(es) – all addresses must be shown together with the Principal in charge of each location:Address Principal in charge

2) Please give the following details for all Partners/Directors/Principals of the Firm(s):

Name Qualifications Date Qualified Age How long as a Partner/Director/Principal


3) Is cover required for predecessor practices to the Proposer(s)?

Is cover required for predecessor practices to the Proposer(s)? YES NOIf “Yes” please provide full details

Name Date commenced Date ceased Reason for cessation

4) Please state total number of:

Please state the number of:

Please state the name of any Professional Body of Trade Association of which the proposer is a member:

Professional Body Trade Association


5) a. Please state gross fees (£) in the columns provided:

Please state gross fees (£) in the columns provided:

Year endPast year ending __ / __ / __

Current year __ / __ / __

Estimate for current year __ / __ / __

UK

USA / Canada (subject to non-USA/Canada law)

USA / Canada (subject to USA/Canada law)

Other overseas

Total

If ‘Other Overseas’ is selected please specify the territory:

5. b. What was the largest fee received from a single client during the last complete financial year?

£

5. c. What was the average fee received for the last complete financial year?

£


6. Have you ever undertaken work in any of the following areas:

a. for Banks or other Financial Institutions/Pension Companies YES NO

b. for Insurance Companies, Lloyd’s Syndicates/Names, Lloyd’s managing or YES NO Members Agents?

c. for any Offshore companies? YES NO

d. for Offshore Funds/Investments (including Isle of Man and Channel Islands)? YES NO

e. for clients in the Entertainment industry? YES NO

f. for Solicitors? YES NO

g. Tax Avoidance Schemes, even if solely as an introducer? YES NO If ‘yes’ please provide additional details in conjunction with this proposal form


7. a. Please categorise your activities and indicate the approximate percentage of the gross fees each represents:

Auditing, accounts and compliance taxation - of public companies %

Auditing, accounts and compliance taxation - of other clients %

Taxation consultancy %

Tax avoidance schemes %

Management consultancy %

Executorship and Trusteeship %

Investment advice (refer to question 7c) %

Directorships %

Secretarial and share registration %

General insurance and building society commissions %

Mergers, acquisitions, disposals %

Work fo merchant banks, finance houses, hire purchase and credit % sales organisations and any other concerns involving finance other than building societies

Probate %

Insolvency – receiverships/administrations %

Insolvency – bankruptcies %

Insolvency - IVAs %

Insolvency – CVAs %

All other work (please provide full details)


7.b. Do you anticipate any major changes in these activities in the YES NO forthcoming 12 months?

If ‘yes’ please provide details:

7.c. Is the Firm authorised, or has it been authorised in the past, to carry our YES NO

investment or financial services work by the FCA (or prior regulators)?

If ‘yes’ please provide details of the extent of activities undertaken and category of authorization:

8. If you have carried out any activities in the last 5 years other than disclosed as part of Question 7.a, please provide details below:

Services provided Year Ending: __ / __ / __ __ / __ / __ __ / __ / __

£ £ £

£ £ £

£ £ £

£ £ £


9. a. Do you sub-contract any work?

a. Do you sub-contract any work? YES NO

If ‘yes’ please provide the following details: What percentage of gross turnover was paid to the sub-contractors % in the last financial year? Are sub-contractors required to carry professional indemnity insurance? YES NO

Do you get an indemnity from sub-contractors in writing? YES NO If yes, to what limits? £

9. b. Do you require any sub-contractor (s) to be indemnified under your insurance? YES NO

If ‘yes’ please state:

Name Qualifications Fees paid in last financial year

£

£

£

10. Do you use a standard form of contract, agreement or letter of appointment?

Do you use a standard form of contract, agreement or letter of appointment? YES NOIf ‘yes’ please provide a copy


11. a. Is the Firm or any Partner or Principal a member of a consortium or Joint Venture?

a. Is the Firm or any Partner or Principal a member of a consortium or Joint Venture? YES NOIf ‘yes’ please provide full details:

Name Capacity Details of job

11. b. Does the Firm or any Partner/Principal/Director act on behalf of, or undertake YES NO work for, any Firm, Company or Organisation in which this Firm or any Partner/ Principal/Director has a financial interest?

11. c. Does any Partner/Principal/Director perform an executive role on behalf of YES NO any such Firm, Company or Organisation?

If ‘yes’ to b or c, please provide details:

12. a. Has the Firm(s) sustained any loss through the fraud or dishonesty of any person?

Has the Firm(s) sustained any loss through the fraud or dishonesty of any person? YES NO

If ‘yes’, please provide details:


12. b. Is the Firm(s) aware of any allegation or occurrence of fraud or dishonesty at YES NO any time committed by any past or present Partner, Director or Employee?If ‘yes’ please provide details and state the precautions taken to prevent reoccurrence:

12. c. Has any person for whom insurance is now sought ever been the subject of YES NO disciplinary proceedings by the ICA or any other professional organisation?If ‘yes’ please provide details:

12. d. Has the Firm(s) or any of its Partners/Principals/Directors ever been a member YES NO of the Assigned Risks Pool (ARP)?If ‘yes’ please provide details:

12. e. Does the Firm (s) always require satisfactory Always Senior appointments only references or only when engaging senior employees?

Nature of reference Written Verbal

12. f. Is any employee allowed to sign cheques on his/her signature alone for YES NO values exceeding £25,000?If ‘yes’ please provide details:


13. Has any insurer ever cancelled, declined, refused to renew or required an increased rate or special conditions in respect of your own or your predecessor(s)’s firm(s)’s insurance?

Has any insurer ever cancelled, declined, refused to renew or required an increased YES NO rate or special conditions in respect of your own or your predecessor(s)’s firm(s)’s insurance?If ‘yes’ please provide full details:

14. Do you currently purchase professional indemnity Insurance?

Do you currently purchase professional indemnity Insurance? YES NO

Is your current insurer ‘Direct Insurance London Market’? YES NOIf ‘No’ please provide the following details:

Renewal Date

Limit of Indemnity £

Excess £

Premium £

Current Insurer


15. Please specify: The limit(s) of indemnity you require quotations for:

Please specify: The limit(s) of indemnity you require quotations for:

£ £ £ £

£ £ £ £

Please state the excess you are prepared to carry:

£ £ £ £

£ £ £ £

16. Have any claims, whether successful or not been made against the Firm(s) or their predecessors in business or any of the present or former Partners, Principals or Directors?

Have any claims, whether successful or not been made against the Firm(s) or their YES NO predecessors in business or any of the present or former Partners, Principals or Directors? If ‘yes’ please provide details:


17. Is any Partner, Principal, Director or employee after inquiry, aware of any circumstance or occurrences which may give rise to a claim against the Firm(s) or their predecessors in business or any of the present or former Partners, Principals or Directors?

Is any Partner, Principal, Director or employee after inquiry, aware of any circumstance or YES NO occurrences which may give rise to a claim against the Firm(s) or their predecessors in business or any of the present or former Partners, Principals or Directors? If ‘yes’ please provide details:

DeclarationI/we declare that I/we have made a fair presentation of the risk, by disclosing all material matters which I/we know or ought to know or, failing that, by giving the Insurer sufficient information to put a prudent insurer on notice that it needs to make further enquiries in order to reveal material circumstances.

Name of Director/Officer/Board member/senior manager:

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

Signature of Director/Officer/Board member/senior manager

Position Held: ............................................................................................................................................................................................

For and on behalf of: ..................................................................................................... Date: .....................................................

Please note: unless dated this Proposal Form will not be valid.

Signing this Proposal Form does not bind the Proposer to enter into a contract of insurance.It is agreed that underwriters are authorised to make investigation and inquiry in connection with this Proposal Form or any Questionnaire that they deem necessary.

www.dilm.co.uk

Direct Insurance London Market

5th Floor, 35 Great St. Helens,

London, EC3A 6HB

t +44 (0) 20 3818 8060e [email protected]

Accountant Proposal Form - Direct Insurance …...2019/01/18 · Accountant Proposal Form 5 / 14 6....

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Transcript of Accountant Proposal Form - Direct Insurance …...2019/01/18 · Accountant Proposal Form 5 / 14 6....