#03-03 Sims Avenue Centre, 540 Sims Avenue, Singapore 387603
Tel : 67474333 Fax : 67470712
NOTICE: / Statement pursuant to Sect 25(5) of the Insurance Act, (Cap 142) or any amendments thereof; you are to disclose in this application fully and faithfully, all the facts which you know or ought to know, otherwise the policy issued may be void and you may receive nothing from this policy.Proposal and Application Form for Architects
Professional Liability Insurance
This form must be signed by a partner or principal of the firm and all questions must be answered. The completion and signature of this form does not bind the firm or underwriters to complete a contract of insurance. If space for any answer is insufficient, please attach separate sheets identifying questions by numbers.A1. / Name of firm
A2. / Address of head office
A3. / Address of branch office(s) and name(s) of resident partner. (If there is no resident partner at any branch office, provide full details of supervision with qualifications and experience of supervisor). / Address / Resident Partner(s)
A4. / During the past five years, has the name of the firm been changed or has any other firm been purchased or any merger or consolidation taken place? / Yes
No / If “Yes”, give full details
A5. / When was firm established? (if under five years, give full details of previous activities of all partners or principals).
A6. / Names and other information of all practising partners or principals.
Name / Qualifications & date qualified / How long practising with
This firm Previous firms
A7. / Names and other information of all retired or deceased partners not in practice, If insurance is required for them, please indicate below.
Name / When joined firm / When left firm / Is insurance required
B1. / Total number of partners, principals and staff / Specify (f) and (g) here
Technical -
/ (a) Partners, principals or officers / (a)(b) Other qualified engineers / (b)
(c) Qualified architects / (c)
(d) Surveyors / (d)
(e) Draughtsmen / (e)
(f) Other qualified staff (specify) / (f)
(g) Trainee staff (specify) / (g)
Total Technical
Non -
Technical -
/ such as administration, clerical, typists, messengers, office boysTotal Non-Technical
B2. / What are the dates of your firm’s financial year / From / to
B3. / What are the gross fees for the following
(a) Domestic Operations / Last Financial
Year (Audited) / Estimate for
Current
Financial Year / Estimate for
Next
Financial Year
- Gross Fees
(b) Foreign Operations (if any)
- Gross Fees
B4. / When engaging independent or specialist consultants in connection with any contract, do you ensure that such consultants have entered into a binding contract with the principal, accepting full responsibility for their own professional acts, errors or omissions? If “No”, do you ensure that such consultants carry professional liability insurance with adequate limits (Not less than those carried by your firm) / Yes
No
Yes
No
B5. / Does your firm engage in or any partners or principal have any interest in any business which engages in any process of manufacture, construction, erection, supply or any form of contracting? / Yes
No / If “Yes” to any of these questions, give full details.
B6. / Is your firm or any partner or principal a member of a consortium (Your attention is drawn to the fact that the insurance to be provided excludes any work which your firm carries out as a member of a consortium) / Yes
No
B7. / What amount of insurance indemnity do you require (list alternatives if desired) / $
$
$
What amount of excess is your firm prepared to carry for each and every claim (list alternatives if desired) / $
B8.
$
$
C1. / Does your firm undertake foreign projects?
If “Yes”, which jurisdiction applies to these contracts / Yes No
Domestic
Foreign / If “Yes”, state countries involved.
C2. / List at least five largest and five typical jobs performed by your firm during the last five years
Description / Location / Value / Fee Received
C3. / In which of the following professions is your firm engaged? / C5. / Does your firm engage in contracts involving any of the following types of work. Indicate the approximate percentage of total gross fees derived from such work in the current financial year.
a) Civil Engineering
b) Structural Engineering / Yes / No
c) Mechanical Engineering / a) Bridges / %
d) Electrical Engineering / b) Tunnels / %
e) Heating & Ventilation Engineering / c) Dams / %
f) Chemical Engineering / d) Mines / %
g) Soil Engineering / e) Harbours or Jetties / %
h) Nuclear Engineering / f) Sewage Schemes / %
i) Architects / g) Foundations & Underpinning / %
j) Interior Design / h) Soil Testing / %
k) Others Not Shown (please specify) / i) Water Schemes / %
j) Nuclear or Atomic Projects / %
k) Fertilizer, Amonia or Urea Plants / %
l) Industrial Systems Buildings / %
m) Restoration Work / %
n) High Rise Buildings / %
(over 10 storeys)
C4. / Indicate the approximate percentage of your total work involving: / o) Heating, Ventilating, / %
Air-conditioning
p) Chemicals, Petro-chemical & / %
a) Feasibility studies, reports, surveys, etc. (where you are not involved in actual design works) / Refineries
q) Mechanical Plant & Bulk Handling / %
Equipment
% / (including soils, etc)
b) Supervision of construction from design made by other firms / r) Work involving any of the / %
following (underline which):
% / Armories, Auditorium, Stadia,
c) Design work without construction supervision / Churches, Concert Halls,
Convention Buildings, Dance
% / Halls, Exhibition Buildings,
d) Both design and supervision of construction / Hotels, Night Clubs, Race Tracks,
% / Restaurants, Theatres, Sport Arenas
s) Other work involving any special / %
activities not shown above
100 / % / (Please specify)
Total 100%
D1. / Has any application for insurance on behalf of the firm or their predecessors in business or any of the present partners or principals been declined for has any such insurance been cancelled or renewal refused or have special terms imposed? / Yes
No / If “Yes”, to any of these questions, give full details.
D2. / Have any claims been made against, or negligence alleged against firm or their predecessors in business or any of the present or former partners or principals? / Yes
No
D3. / Are any partners or principals, after enquiry, aware of any circumstances which may result in any claim being made against the firm, its predecessors in business or any of its present or former partners or principals? / Yes
No
D4. / Is the firm at present or has it in the past insured for professional liability risks? If “Yes”, please state:- / Yes
No
a) Name of Insurers
b) Amount of insurance
c) Excess to be borne by firm
d) Premium Paid
e) Expiry date of the policy
I/We declare that the statements and particulars in this proposal are true and that I/We have not mis-stated or suppressed any material facts. I/We agree that this proposal, together with any other information supplied by me/us shall form the basis of any contract of insurance effected thereon. I/We undertake to inform insurers of any material alteration to these facts whether occurring before or after completion of the contract of insurance.
I/We agree to allow Able Insurance Brokers Pte Ltd (Able) to collect, use and disclose all personal data which Able has been provided and has possessed for the purpose of handling, processing and providing its services. I/We agree that Able may transfer my/our personal data to Able related group of companies and/or third party service providers, insurers, reinsurers, suppliers or intermediaries whether located in Singapore or elsewhere for the above purposes.
Date of Signature / Place of Signature
Signature of Partner or Principal
/ Company Stamp / Name of Signatory
This form must be signed by a partner or principal of the firm and all questions must be answered. The completion and signature of this form does not bind the firm or underwriters to complete a contract of insurance. If space for any answer is insufficient, please attach separate sheets identifying questions by numbers.
Extensions to Basic Insurance Cover
Please complete these questions if any extensions are desired. An additional premium is charged.* NOTE – Policy coverage is only briefly outlined here. For full details, please refer to the policy.
Extensions 1 – Loss of Documents
· This extension insures liability for destroyed, damaged, lost or mislaid documents whilst in the custody of the firm.Do you require insurance for this extension? / Yes / No / Describe storage if other than fireproof cabinets.
If “Yes”, do you keep documents in fire-proof cabinets. / Yes / No
Extensions 2 – Partner’s Previous Business
· This extension insures liability before the firm of INCOMING PARTNERS and after leaving the firm of OUTGOING PARTNERS.Do you required insurance for :- / If “Yes”, give names of partners for whom insurance is required.
a) Incoming partners? / Yes / No
b) Outgoing partners? / Yes / No
Extensions 3 – Libel and Slander
· This extension insures liability for claims arising from civil libel or slander. / If “Yes”, give details of any claim made against firm involving libel and slander.
Do you require insurance for this extension? / Yes / No
Extensions 4 – Dishonesty of Employees· This extension insures liability for dishonesty, fraudulent, criminal or malicious acts of employees.
Do you require insurance for this extension?
If “Yes”, please answer the following questions: / Yes / No
Has the firm sustained any loss through the fraud or dishonesty of employee? / Yes / No
Does the firm know of any fraud or dishonesty at any time of any present or former employee? / Yes / No
Does the firm always obtain satisfactory reference when engaging employees? / Yes / No
Is any employee allowed to sign cheques without countersignature by a partner? / Yes / No
If “Yes”, up to what amount? / $
5
Forms\PI\ArchPIFormFieldj2014.doc