PROPOSAL FORM FOR PROFESSIONAL INDEMNITY INSURANCE

1.
(a) Name of Proposer

(b) Address

(c ) Telephone Numbers

(d) Fax Numbers

(e) e-mail address

2.
(a) When was the company commenced
and business established

(b) If it is a Government Company,

whether it is by a special statute or a
part of the Government Departments

3.
(a) In which type of profession is the
proposer mainly engaged?
Give details

(b) Apart from the above, is there any

other professional work which the
proposer undertakes?

4.
(a) Please indicate the places of business
in Zambia and names of persons who
have powers to bind the organisation.

5. Please give the following particulars for each Director/Trustee/Partner

NAME AGE PROFESSIONAL DATE OF RESPONSIBLE
QUALIFICATIONS APPOINTMENT FOR
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6.
Please indicate the nature of establishment
the proposer maintains to carry out the
professional work indicating names of
professionally qualified employees.
7. Please indicate the total number of
(a) Directors/Trustees/Partners

(b) Managers/Officers and other employees in

difference cadres

8. Has the proposer or have the proposers, predecessors in business discharged

or is the proposer contemplating to discharge/terminate any employee for:
(a) Any negligent Act, error or omission, or
commission

(b) Any dishonest, fraudulent, criminal or

malicious conduct? If so, give details.

9.
Is the Proposer now or ever been insured
against professional indemnity risk? If so,
state with what company or companies?

10.
(a) Has any one made any claim for breach of
professional duty against the Proposer or the
Proposer’s predecessors in business or against
any Partner/Director individually or has the
Proposer any reason to suspect that such a
claim could be made? If so, give full
particulars.

(b) Give below particulars of all professional

indemnity claims made by the Proposer or the
Proposers’ predecessors in business during the
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past five years

NO. OF NO. OF AMOUNT AMOUNT TO

YEAR EVENTS INSURERS RECOVERED BE
RECOVERED
20
20
20
20
20
11.
Is there any other information material to the
risk in the Proposer’s possession? If so, give
full details
12. Has any insurer previously granted a cover in respect of the risk proposed for
insurance? If so, please state
(a) Name of insurer

(b) The period of insurance

13. Has any insurer in respect of any professional indemnity cover

(a) Declined a proposal from the proposer or from
the proposer’s predecessors in business, or
(b) Cancelled or declined to renew any policy, or
(c ) Demanded an increased rate, or
(d) Required special terms to insure or grant any
renewal?
14. Amount of indemnity required
(a) Any one event or series of events arising out
of any one cause.
(b) All events during the period of insurance

15.
Period of Insurance From

To
16.
If any specific official(s) to be insured, please 1.
indicate name and limits against each of them
2.

3.

4.

5.
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17.
Please give gross fees received during the past
five years
1. K

2. K

3. K

4. K

5. K

Estimated fees for the coming 12 months

K………………………………………………………………..

18. Does the Proposer wish to extend the policy to cover

(a) Dishonest, Fraudulent, Criminal or Malicious
acts of employees in relation the Proposer’s
Professional work.
(b) Loss of or damage to documents? (What will be
the greatest value at risk at any one time?)

If so
(i) State the amounts to the insured under each
(ii) Give details of any claim(s) or loss(es) under
the extension(s) required
(If the space provided is not adequate, please use additional sheets)

I/We hereby declare that the above statements and answers are true and complete
and that no material fact has been with-held, mis-stated or mis-represented and that
I/We agree that this proposal and declaration shall be the basis of the contract
between me/us and GENERAL ALLIANCE INSURANCE ZAMBIA LTD.

PLACE: …………………………………………………

DATE: …………………………………………………… ………………………………………….

SIGNATURE OF PROPOSER

(A Partner/Director of the Firm/Company must sign this Proposal Form)

Note: The liability of the company does not commence until the proposal has been
accepted by the Company and the premium paid.