1. Title/Company/TradingName(s):
(include previous trading styles) / ‘The Firm’ / 2. Date 1st Established:
3. The Firms Business Description:
4. Primary Address:
5. Contact Telephone Number:

6. Details of main Principals, Partners or Directors of The Firm:

Full Name / D.O.B / Qualifications/Experience
attach CV if available
attach CV if available

7. Please state number of (in-house, PAYE):

Directors/Principals / 1. Qualified/Technical Staff (Fee Earners) / 2. All other Staff

< Please include the Directors/Principals under the 2 categories above >

8 a. Are The Firms Key Persons (Fee Earners) covered in the event of Death/Illness/Disability? / Yes / No
b. Does The Firm have any locum agreements in force to ensure delivery of services if Fee Earners are incapacitated? / Yes / No

9. Please state The Firms Governing body:

ICA / CIOT / ATT / ACCA / AAT / CIMA / Other
10. (where applicable provide indications of The Firms income) / UK Only / Europe / USA/Canada / Elsewhere
Gross Fee income for financial year(2014 to 2015) / £ / £/€ / £/$ / £
Gross Fee income for financial year(2015 to 2016) / £ / £/€ / £/$ / £
Gross Fee income for financial year(2016 to 2017) / £ / £/€ / £/$ / £
Estimate of Gross Fee income for financial year(2017 to 2018) / £ / est / £/€ / est / £/$ / est / £ / est

11. Please provide a percentage breakdown of The Firms fees between the following groups over the last financial year (a, b, c):

(a) Clients invoiced less than £10k per year / %
What services are provided to clients in groups b c:
(b) Clients invoiced between £10k to £25k / % / No. of clients:
(c) Clients invoiced over £25k / % / No. of clients:
Total / 100 %

12. Please provide a breakdown of The Firm Activities/Services provided; with % breakdown (please estimate if no historical data):

General Accountancy / %
Book-keeping / Payroll Services / %
Company Compliance Tax (Tax Returns etc) / %
Personal Taxation Only / %
Non Compliance Tax Work (Capital Gains planning etc.) / %
Audits / %
Financial Services / %
Insolvency Work / %
Insurance / %
General Business / Management Consultancy / %
IT Consultancy / %
Other (please specify) / %
Total: / 100%
13. Has the The Firmever provided any advice or been involved in arranging Financial Services Products?
(Other than introducing clients to an independent third party adviser) / Yes / No
14. Has the The Firm carried out work relating to; Lloyd’s of London or any Lloyd’s managing agents or members' agents, Clients in the “Entertainment” industry, Quoted Companies, Public Limited Companies, or any ‘off-shore’ companies? / Yes / No
15. Has The Firmprovided any advice in relation to tax planning schemes (company or personal) that could be considered as tax avoidance, even if only as an introducer? / Yes / No
16. Has the The Firmever been involved in advising any clients in relation to film finance tax reduction schemes? / Yes / No

17. Claims and other Circumstance Statements

(a) No claims for professional negligence, error or omissions or the like have ever been made against The Firmor any predecessor(s) in business or against any Partners/Directors/Principals either directly or in respect of any Company of which they were a Partner/Director/Principal of. / True / False
(b) After enquiry within The Firmthe Proposer is not aware of any circumstances which have occurred which may give rise to a claim. / True / False
(c)The Firmor any Partners/Directors/Principal has not had any Insurers decline to offer PI renewal terms, nor has had their PI policy cancelled or voided, or had any special premium increase or special terms being imposed due to a material fact. / True / False
(d)The Firmor any Partners/Directors/Principal do not act, or have not acted, in any capacity other than those declared. / True / False
(e)The Firmor any Partners/Directors/Principal have not ever been the subject of investigations or disciplinary proceedings by any Regulatory Body. / True / False
(f)The Firmor any Partners/Directors/Principal do not undertake work for any partnership, company or organisation in which they are in a position to exercise a controlling interest in such a partnership, company, organisation. / True / False

If you answer ‘Yes/False’, to any of the questions above please provide details.

18.Does The Firmcurrently hold Professional Indemnity Insurance? / Yes / No
Current PI insurers/security:
Current PI broker:
Current Premium:
19. What PI Limit(s) of Indemnity does The Firmrequire? / £ / £ / £
20. Renewal Date/Cover Start Date
21. Professional Indemnity Excess

Please indicate below if you would like us to review any additional covers:

Public/Products Liability Insurance / Key Man Cover/Business Interruption
Commercial Legal Expenses (HMRC Queries, Contract disputes) / Cyber Liability – IT Hacker/Security Cover
Directors & Officers / Corporate Liability Insurance / Employers Liability (EL)
Contents/Computers Insurance / EL is Legally required for any “Ltd” Firms with 2≥ Directors
I/we declare that, after full enquiry, the contents of this proposal are true and that I/we have not misstated, omitted or suppressed any material fact or information. I/we agree that this proposal together with any other information supplied by me/us shall form the basis of any contract of insurance which may be affected. If there is any material alteration to the facts and information which I/we have provided or any new material matter arises before the completion of the contract of insurance, I/we undertake to inform Underwriters.
Signature of Principal: / Date:
<Insurers do not accept electronically typed Names as signatures>
Please disclose any information/material facts which might influence the insurer in deciding whether or not to accept the risk: