PROFESSIONAL INDEMNITY PROPOSAL OHSA RELATED PROFESSIONALS (Short Form)

Status : New

1. Proposer Details :

2. Address Of Practice :

3. Date Of Commencement Of Practice :

4. Name Of Principals :

Principals
Name How long Principal in this Practice

Add Principal

Claims
Have any claims been made against the proposed Insured Details about the claim Any circumstances which would may result in any claims or any possible claims being made against you Details about the circumstances

Add Claim

If Yes, please tick box
If Yes, please tick box
Insurance
Name of Insurers Date cover expires/d Retroactive Date i)declined a Proposal or renewal for this Practice or any Partner / Principal? ii)required an increased premium or imposed special terms? iii)cancelled an Insurance? If yes, please provide full details

Add Insurance History

If Yes, please tick box
If Yes, please tick box
If Yes, please tick box

Does this practice undertake any work outside of RSA?

If Yes, please tick box
If yes, Please provide full details:

5. Detailed Business Description :

6. Fee Income - As At The Practice's Financial Year End :

7. Product Details :