| |
|
| Your name
(or Firm's) |
|
| E-mail
address |
|
| Address |
|
| Post
code |
|
| Telephone
No. |
|
| Date
Established |
|
Full
description of
business activities
& responsibilities |
|
Associated
with any
other firm(s)? |
Details |
| Details of
ALL Principals, Partners or Directors (If unqualified
please provide a brief CV) Name
of Person : Age : Qualifications : Date Qualified :
Number of Years with this firm
|
| Numbers
of Staff
|
|
|
If a sole
practitioner, please give details of Professional
cover in the event of holiday/ sickness etc.
|
Annual fee
income for last 3 years and estimate for forthcoming
year
(If new practice please provide a first year project)
1997 :
1998 :
1999 :
2000 :
2001 : (est.) date of year end |
| Percentage
Split (last year) |
UK Europe USA Rest of World (total 100) |
Description of areas
of activity
............................................
Percentage
(Please provide further details below if necessary) |
| Current
Insurance |
|
|
| Cover now
required |
Limit Excess
|
|
|
Has any insurer ever
declined to offer terms, imposed special terms or
cancelled or voided
any insurance for the firm or any Principal, Partner
or Director? (If 'yes' give details below) |
|
|
Have any claims been
made against the Firm or its predecessors or any past
or present
Principal, Partner or Director, whether successful or
not? (If 'yes' give details below) |
|
|
Are you or any of
the Principals, Partners, Directors or employees
AFTER FULL ENQUIRY
aware of any circumstances which may give rise to a
claim agains the Firm or its predecessors
or any past or present Principal, Partner, Director
or Employee? (If yes please give details) |
| Comments
further info etc |
|
| Have you any specific demands and needs? |
|
|
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