Town planners proposal form - Bluefin Group
Professional indemnity insurance Royal town planners proposal form Instructions Please provide a full answer to every question. Please ensure that all answers are typewritten or printed in block letters within the spaces provided. A principal of the practice must sign and date this form and any separate sheets. 1 Name and address details Practice name (include all names under which you practice)
Main office address Telephone number
Contact e-mail address Postcode: Employer’s Reference Number (ERN) (found on PAYE documents)
Practice website
Date established
List number of branch offices
/
/
Please list on a separate sheet all branch offices including addresses for which you are seeking cover. 2 Firm changes Has the name of the Firm(s) changed or has any amalgamation or take-over taken place during the past six years? If ‘Yes’, please give details
Yes
No
3 The firm Please advise the following (including details of sole practitioner). Name of all partners / directors / members
Age
Qualifications
How long as partner / director/ member of the firm(s)
Date qualified /
/
/
/
/
/
/
/
/
/
4 Previous partners cover Is cover required for any Partner / Director / Member in respect of his/her liability arising from any previous business?
Yes
No
If ‘Yes’, please advise: For which Partners / Directors / Members
Bluefin Professions | RTPI v3.0
Title of previous business
Date left Business
Limit of Indemnity required if less than that of current firm
/
/
£
/
/
£
/
/
£
5 Staff Please advise the number of: Staff who are members of the Royal Town Planning Institute
Other staff with Professional Qualifications
Other Full-Time staff
Permanent Part-Time staff
Any other occasional associated professionals (excluding sub-consultants) 6 Sub-consultants 6.1
Is any work undertaken by Sub-Consultants?
Yes
No
If ‘Yes’, please advise nature of work
6.2
If Sub-Consultants are used, are they appointed directly by and paid by the Client?
Yes
No
6.3
Do Sub-Consultants employed carry insurance to cover their liability for such work?
Yes
No
Yes
No
Yes
No
Yes
No
7 Partner / director / member interests 7.1
Does the Firm(s) or any Partner , Director or Member have any financial interest in any other professional firm or practice? If ‘Yes’, please give name and nature of business.
Is it intended to provide professional services to such firm or practice? If ‘Yes’, please give details
7.2
Does any Partner , Director or Member or hold any Directorships or Appointments in Companies or other organisations. (e.g. Housing Associations, Trusts)? If ‘Yes’, and cover is required for professional services provided to such Companies or organisations, please give: Individuals Name
Nature of Appointment
Nature of Company or Organisation
Nature of Services Provided
Cover is not normally available for work done for companies in which your partners / directors / members have a controlling interest 7.3
Do the Partners, Directors or Member s have a Controlling Interest in any of these organisations? If ‘Yes’, please give details
Yes
No
8 Fees State the gross fees received for the last two years and provide an estimate for the forthcoming year Last Financial Year
Previous Financial Year
Estimate for Current Year
United Kingdom
£
£
£
Republic of Ireland
£
£
£
Overseas (Non USA / Canada)
£
£
£
USA / Canada
£
£
£
Total
£
£
£
Last Financial Year
Previous Financial Year
Estimate for Current Year
£
£
£
Please state financial year end date
/
/
State the gross fees paid to Sub-Consultants
Payments to Sub-Consultants
State total gross earnings in respect of services provided as a Planning Inspector for the Department of the Environment or a Planning Reporter for the Scottish Office. Last Financial Year
Previous Financial Year
Estimate for Current Year
£
£
£
9 Percentage of business Please state percentage of business relative to the types of work undertaken by the Firm: 1
Town Planning
%
2
Other Work
%
Total
(i)
Landscape Architecture
%
(ii)
Minerals (other than income derived from negotiating and obtaining planning permission for minerals working).
%
(iii)
Advice of economic viability
%
(iv)
Highway and access design
%
(v)
Architectural (if contracts undertaken on terms other than RICS Conditions of engagement for Architectural services or standard RIBA terms of engagement, please give details).
%
(vi)
General Practice Surveying
%
(vii)
Property / Estate / Land Management (excluding “Minerals”)
%
(viii)
Estate / House Agency
%
(ix)
Valuations / Structural Surveys (Residential)
%
(x)
Valuations / Structural Surveys (Commercial)
%
(xi)
Building Surveying
%
(xii)
Land Surveys / Valuations
%
(xiii)
Quantity Surveying
%
(xiv)
Project Management
%
(xv)
Building Society Agency
%
(xvi)
Insurance Agency
%
(xvii)
Loss Assessing or Adjusting
%
(xviii)
Any work not mentioned above (Please give details on a separate sheet)
% 100%
10 Largest contracts Please give details of five largest contracts during the past six years, if applicable: Contract Value
Nature of Building
Extent of Responsibilities (tick as necessary) DO
DS
DSPM
£ £ £ £ £ DO = Design Only
DSPM = Design, Supervision & Project Management
DS = Design & Supervision
REF = Refurbishment / Planned Maintenance Surveys where load bearing walls are affected
11 Overseas work 11.1
In which Countries does / will the Firm(s) operate?
11.2
Please advise how overseas work is controlled
12 Substantial changes Does the Company/Firm foresee any substantial change to the breakdown in work, or the undertaking of any new operations during the next twelve months?
Yes
No
Yes
No
If ‘Yes’, please advise.
13 Non-chargeable fees Does the proposer undertake any work for which fees are NOT charged? (e.g. Charitable works) If ‘Yes’, please advise.
14 Percentage of business details Under Question 9, for any activities where you have answered ‘Nil’, give details if you have been engaged in such work in the last six years.
15 Asbestos work (a)
Carried out any assessment, planning or reporting, or executed any plan of work as described in the Control of Asbestos at Work Regulations 2002 (CAWR)?
Yes
No
(b)
Provided any other advice, design or specification in relation to the manufacture, process, supply, use, removal or disposal of asbestos or any asbestos containing material?
Yes
No
(c)
Assumed the responsibilities of “Duty Holder” as defined in the Control of Asbestos at Work Regulations 2002 (CAWR)?
Yes
No
(d)
Do you propose to undertake any of the above (a) (b) or (c) during the forthcoming period of insurance?
Yes
No
If Yes’, to (a),(b),(c) or (d), an Asbestos Questionnaire will need to be completed – please contact us for details.
REF
16 Fraud and dishonesty 16.1
Has the Firm(s) sustained any loss through the fraud or dishonesty of any person during the past six years?
Yes
No
If ‘Yes’, please advise
16.2
Does the Firm(s) obtain references when engaging new employees?
Yes
No
16.3
Will any Partner, Director Member or Employee be permitted to draw cheques on their sole signature in respect of the Firm(s) or Clients(s) accounts?
Yes
No
If ‘Yes’, please state who and to what limit
16.4
Does the Firm(s) have a separate client account for the holding of Planning Application Funds? (N.B. Insurers consider the maintenance of a separate clients account to be a good risk feature)
Yes
No
16.5
Please confirm that the Annual Accounts have been prepared and/or certified by an independent Accountant or Auditor?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
17 Previous insurance Has any Proposal for Professional Indemnity, Fraud or Dishonesty risks made on behalf of the Firm(s), any predecessors in business, or present Partners, Directors or Members, ever been declined or has any such Insurance been cancelled or renewal refused or special terms imposed? If ‘Yes’, please give full details.
18 Claims and circumstances Have any claims been made against the Firm(s) or its/their predecessors in business or its/their present of former Partners, Directors or Members in respect of liabilities to be covered by the proposed Professional Indemnity Insurance during the past six years? If ‘Yes’, please give full details including dates, description of loss and amounts involved
After FULL ENQUIRY are any Partners, Directors or Members aware of any claims and / or circumstances which may give rise to a claim against the Firm(s) or its predecessors in business or the present or former Partners , Directors or Members in respect of liabilities to be covered by the proposed Professional Indemnity Insurance during the last six years? If ‘Yes’, please give full details. If insufficient space is provided please continue on a separate sheet.
19 Sanctions Do you have any connection to customers or suppliers operating in the following countries or are any form of product or service sourced from or passed through these countries or indeed any employees who would visit any of these countries on business: Iran, Syria, Belarus, South Sudan, Cuba, Democratic Republic of Congo, North Korea, Somalia, Sudan, Zimbabwe, Russia, Ukraine, Crimea.
20 Disciplinary proceedings Has any proposer / director / partner of the business: (i)
Been declared insolvent or bankrupt or been the subject of bankruptcy proceedings?
Yes
No
(ii)
Been the subject of a County Court judgment (or Scottish equivalent) or are there any proceedings pending?
Yes
No
(iii)
Been a director or partner in any business which is or has been the subject of a winding up or administrative order, or receivership or other insolvency proceedings?
Yes
No
(iv)
Had a proposal form declined?
Yes
No
(v)
Had an insurance cancelled?
Yes
No
(vi)
Had special terms imposed?
Yes
No
(vii) Been convicted or charged with any criminal offence, or have a prosecution for such an offence pending?
Yes
No
(viii) Been prosecuted or served with a notice of intended prosecution or a prohibition notice in connection with a breach or alleged breach of any health and safety legislation?
Yes
No
If ‘Yes’, please provide details:
21 Quotation requirements Please give details of the firm’s current Professional Indemnity Insurance. Do not complete this question if you are already a client of Bluefin Limit of indemnity
Excess
Premium
£
£
£
Name of insurer
Renewal date /
Please advise your requirements Option 1
Option 2
Option 3
Limit of indemnity
£
£
£
Excess
£
£
£
People consulted in completion of the form Please list below the people you have consulted to assist with the completion of this form, including any external providers: Name
Please continue on a separate sheet if necessary.
Position
Location
/
Confirmation Your duty to make a fair presentation of the risk You must make a fair presentation of the risk to us when you take out, renew or amend your policy. A fair presentation requires you to tell us about all facts and circumstances which may be material to the insurance or sufficient information to put a prudent insurer on notice that further enquiries are needed, in a clear and accessible manner. Material facts are those which are likely to influence an insurer in the acceptance or assessment of the terms or pricing of your policy. If you are in any doubt as to whether a fact is material, you should tell us about it. If you fail to make a fair presentation of the risk, where that failure is deliberate or reckless, the insurer may treat your policy as if it had not existed, refuse to pay any claims and keep the premium paid. Where the failure is not deliberate or reckless but the insurer would not have accepted the policy had you told them about a material fact or circumstance, the insurer may treat your policy as if it had not existed and refuse to pay any claims but must return the premium. In other cases, the insurer may only pay part of the value of your claim or impose additional terms. For these reasons, it is important that you check all of the facts, statements and information set out in the documentation provided by us are complete and accurate, and that you answer any questions completely and accurately. If there is more than one person involved in your business or employed by you, you should check with them, where appropriate, that the facts and statements that you make are complete and accurate. If any of the facts, statements and information in this document, or any additional information provided are incomplete or inaccurate, you must contact us immediately. Failure to do so could invalidate your policy or lead to a claim not being paid. I declare that the above statements and particulars are true, full enquiry having been made, and I have not omitted, suppressed or misstated any material facts and undertake to inform the insurer of any change to any material fact. I understand that the information provided will be used by the insurer and/or their agents to arrange and administer the insurance and in handling claims which may necessitate sharing information with third parties and that information may be shared with business partners to deliver any additional services provided with this insurance. A copy of this proposal should be retained by you for your own records This form must be signed by a principal of the firm
Signature:
Date:
Print name:
Position:
/
/
Please return this application form along with any other supplementary information sheets to the contact details on the covering letter.
Bluefin Professions is a trading name of Bluefin Insurance Services Limited. Registered Office: 1 Tower Place West, Tower Place, London, EC3R 5BU. Registered in England No: 931954. Authorised and regulated by the Financial Conduct Authority.
© 2016 Bluefin Insurance Services Limited
Main office address Telephone number
Contact e-mail address Postcode: Employer’s Reference Number (ERN) (found on PAYE documents)
Practice website
Date established
List number of branch offices
/
/
Please list on a separate sheet all branch offices including addresses for which you are seeking cover. 2 Firm changes Has the name of the Firm(s) changed or has any amalgamation or take-over taken place during the past six years? If ‘Yes’, please give details
Yes
No
3 The firm Please advise the following (including details of sole practitioner). Name of all partners / directors / members
Age
Qualifications
How long as partner / director/ member of the firm(s)
Date qualified /
/
/
/
/
/
/
/
/
/
4 Previous partners cover Is cover required for any Partner / Director / Member in respect of his/her liability arising from any previous business?
Yes
No
If ‘Yes’, please advise: For which Partners / Directors / Members
Bluefin Professions | RTPI v3.0
Title of previous business
Date left Business
Limit of Indemnity required if less than that of current firm
/
/
£
/
/
£
/
/
£
5 Staff Please advise the number of: Staff who are members of the Royal Town Planning Institute
Other staff with Professional Qualifications
Other Full-Time staff
Permanent Part-Time staff
Any other occasional associated professionals (excluding sub-consultants) 6 Sub-consultants 6.1
Is any work undertaken by Sub-Consultants?
Yes
No
If ‘Yes’, please advise nature of work
6.2
If Sub-Consultants are used, are they appointed directly by and paid by the Client?
Yes
No
6.3
Do Sub-Consultants employed carry insurance to cover their liability for such work?
Yes
No
Yes
No
Yes
No
Yes
No
7 Partner / director / member interests 7.1
Does the Firm(s) or any Partner , Director or Member have any financial interest in any other professional firm or practice? If ‘Yes’, please give name and nature of business.
Is it intended to provide professional services to such firm or practice? If ‘Yes’, please give details
7.2
Does any Partner , Director or Member or hold any Directorships or Appointments in Companies or other organisations. (e.g. Housing Associations, Trusts)? If ‘Yes’, and cover is required for professional services provided to such Companies or organisations, please give: Individuals Name
Nature of Appointment
Nature of Company or Organisation
Nature of Services Provided
Cover is not normally available for work done for companies in which your partners / directors / members have a controlling interest 7.3
Do the Partners, Directors or Member s have a Controlling Interest in any of these organisations? If ‘Yes’, please give details
Yes
No
8 Fees State the gross fees received for the last two years and provide an estimate for the forthcoming year Last Financial Year
Previous Financial Year
Estimate for Current Year
United Kingdom
£
£
£
Republic of Ireland
£
£
£
Overseas (Non USA / Canada)
£
£
£
USA / Canada
£
£
£
Total
£
£
£
Last Financial Year
Previous Financial Year
Estimate for Current Year
£
£
£
Please state financial year end date
/
/
State the gross fees paid to Sub-Consultants
Payments to Sub-Consultants
State total gross earnings in respect of services provided as a Planning Inspector for the Department of the Environment or a Planning Reporter for the Scottish Office. Last Financial Year
Previous Financial Year
Estimate for Current Year
£
£
£
9 Percentage of business Please state percentage of business relative to the types of work undertaken by the Firm: 1
Town Planning
%
2
Other Work
%
Total
(i)
Landscape Architecture
%
(ii)
Minerals (other than income derived from negotiating and obtaining planning permission for minerals working).
%
(iii)
Advice of economic viability
%
(iv)
Highway and access design
%
(v)
Architectural (if contracts undertaken on terms other than RICS Conditions of engagement for Architectural services or standard RIBA terms of engagement, please give details).
%
(vi)
General Practice Surveying
%
(vii)
Property / Estate / Land Management (excluding “Minerals”)
%
(viii)
Estate / House Agency
%
(ix)
Valuations / Structural Surveys (Residential)
%
(x)
Valuations / Structural Surveys (Commercial)
%
(xi)
Building Surveying
%
(xii)
Land Surveys / Valuations
%
(xiii)
Quantity Surveying
%
(xiv)
Project Management
%
(xv)
Building Society Agency
%
(xvi)
Insurance Agency
%
(xvii)
Loss Assessing or Adjusting
%
(xviii)
Any work not mentioned above (Please give details on a separate sheet)
% 100%
10 Largest contracts Please give details of five largest contracts during the past six years, if applicable: Contract Value
Nature of Building
Extent of Responsibilities (tick as necessary) DO
DS
DSPM
£ £ £ £ £ DO = Design Only
DSPM = Design, Supervision & Project Management
DS = Design & Supervision
REF = Refurbishment / Planned Maintenance Surveys where load bearing walls are affected
11 Overseas work 11.1
In which Countries does / will the Firm(s) operate?
11.2
Please advise how overseas work is controlled
12 Substantial changes Does the Company/Firm foresee any substantial change to the breakdown in work, or the undertaking of any new operations during the next twelve months?
Yes
No
Yes
No
If ‘Yes’, please advise.
13 Non-chargeable fees Does the proposer undertake any work for which fees are NOT charged? (e.g. Charitable works) If ‘Yes’, please advise.
14 Percentage of business details Under Question 9, for any activities where you have answered ‘Nil’, give details if you have been engaged in such work in the last six years.
15 Asbestos work (a)
Carried out any assessment, planning or reporting, or executed any plan of work as described in the Control of Asbestos at Work Regulations 2002 (CAWR)?
Yes
No
(b)
Provided any other advice, design or specification in relation to the manufacture, process, supply, use, removal or disposal of asbestos or any asbestos containing material?
Yes
No
(c)
Assumed the responsibilities of “Duty Holder” as defined in the Control of Asbestos at Work Regulations 2002 (CAWR)?
Yes
No
(d)
Do you propose to undertake any of the above (a) (b) or (c) during the forthcoming period of insurance?
Yes
No
If Yes’, to (a),(b),(c) or (d), an Asbestos Questionnaire will need to be completed – please contact us for details.
REF
16 Fraud and dishonesty 16.1
Has the Firm(s) sustained any loss through the fraud or dishonesty of any person during the past six years?
Yes
No
If ‘Yes’, please advise
16.2
Does the Firm(s) obtain references when engaging new employees?
Yes
No
16.3
Will any Partner, Director Member or Employee be permitted to draw cheques on their sole signature in respect of the Firm(s) or Clients(s) accounts?
Yes
No
If ‘Yes’, please state who and to what limit
16.4
Does the Firm(s) have a separate client account for the holding of Planning Application Funds? (N.B. Insurers consider the maintenance of a separate clients account to be a good risk feature)
Yes
No
16.5
Please confirm that the Annual Accounts have been prepared and/or certified by an independent Accountant or Auditor?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
17 Previous insurance Has any Proposal for Professional Indemnity, Fraud or Dishonesty risks made on behalf of the Firm(s), any predecessors in business, or present Partners, Directors or Members, ever been declined or has any such Insurance been cancelled or renewal refused or special terms imposed? If ‘Yes’, please give full details.
18 Claims and circumstances Have any claims been made against the Firm(s) or its/their predecessors in business or its/their present of former Partners, Directors or Members in respect of liabilities to be covered by the proposed Professional Indemnity Insurance during the past six years? If ‘Yes’, please give full details including dates, description of loss and amounts involved
After FULL ENQUIRY are any Partners, Directors or Members aware of any claims and / or circumstances which may give rise to a claim against the Firm(s) or its predecessors in business or the present or former Partners , Directors or Members in respect of liabilities to be covered by the proposed Professional Indemnity Insurance during the last six years? If ‘Yes’, please give full details. If insufficient space is provided please continue on a separate sheet.
19 Sanctions Do you have any connection to customers or suppliers operating in the following countries or are any form of product or service sourced from or passed through these countries or indeed any employees who would visit any of these countries on business: Iran, Syria, Belarus, South Sudan, Cuba, Democratic Republic of Congo, North Korea, Somalia, Sudan, Zimbabwe, Russia, Ukraine, Crimea.
20 Disciplinary proceedings Has any proposer / director / partner of the business: (i)
Been declared insolvent or bankrupt or been the subject of bankruptcy proceedings?
Yes
No
(ii)
Been the subject of a County Court judgment (or Scottish equivalent) or are there any proceedings pending?
Yes
No
(iii)
Been a director or partner in any business which is or has been the subject of a winding up or administrative order, or receivership or other insolvency proceedings?
Yes
No
(iv)
Had a proposal form declined?
Yes
No
(v)
Had an insurance cancelled?
Yes
No
(vi)
Had special terms imposed?
Yes
No
(vii) Been convicted or charged with any criminal offence, or have a prosecution for such an offence pending?
Yes
No
(viii) Been prosecuted or served with a notice of intended prosecution or a prohibition notice in connection with a breach or alleged breach of any health and safety legislation?
Yes
No
If ‘Yes’, please provide details:
21 Quotation requirements Please give details of the firm’s current Professional Indemnity Insurance. Do not complete this question if you are already a client of Bluefin Limit of indemnity
Excess
Premium
£
£
£
Name of insurer
Renewal date /
Please advise your requirements Option 1
Option 2
Option 3
Limit of indemnity
£
£
£
Excess
£
£
£
People consulted in completion of the form Please list below the people you have consulted to assist with the completion of this form, including any external providers: Name
Please continue on a separate sheet if necessary.
Position
Location
/
Confirmation Your duty to make a fair presentation of the risk You must make a fair presentation of the risk to us when you take out, renew or amend your policy. A fair presentation requires you to tell us about all facts and circumstances which may be material to the insurance or sufficient information to put a prudent insurer on notice that further enquiries are needed, in a clear and accessible manner. Material facts are those which are likely to influence an insurer in the acceptance or assessment of the terms or pricing of your policy. If you are in any doubt as to whether a fact is material, you should tell us about it. If you fail to make a fair presentation of the risk, where that failure is deliberate or reckless, the insurer may treat your policy as if it had not existed, refuse to pay any claims and keep the premium paid. Where the failure is not deliberate or reckless but the insurer would not have accepted the policy had you told them about a material fact or circumstance, the insurer may treat your policy as if it had not existed and refuse to pay any claims but must return the premium. In other cases, the insurer may only pay part of the value of your claim or impose additional terms. For these reasons, it is important that you check all of the facts, statements and information set out in the documentation provided by us are complete and accurate, and that you answer any questions completely and accurately. If there is more than one person involved in your business or employed by you, you should check with them, where appropriate, that the facts and statements that you make are complete and accurate. If any of the facts, statements and information in this document, or any additional information provided are incomplete or inaccurate, you must contact us immediately. Failure to do so could invalidate your policy or lead to a claim not being paid. I declare that the above statements and particulars are true, full enquiry having been made, and I have not omitted, suppressed or misstated any material facts and undertake to inform the insurer of any change to any material fact. I understand that the information provided will be used by the insurer and/or their agents to arrange and administer the insurance and in handling claims which may necessitate sharing information with third parties and that information may be shared with business partners to deliver any additional services provided with this insurance. A copy of this proposal should be retained by you for your own records This form must be signed by a principal of the firm
Signature:
Date:
Print name:
Position:
/
/
Please return this application form along with any other supplementary information sheets to the contact details on the covering letter.
Bluefin Professions is a trading name of Bluefin Insurance Services Limited. Registered Office: 1 Tower Place West, Tower Place, London, EC3R 5BU. Registered in England No: 931954. Authorised and regulated by the Financial Conduct Authority.
© 2016 Bluefin Insurance Services Limited
