Marine Surveyor & Marine Consultant – Proposal Form

PLEASE PRINT AND COMPLETE ALL PAGES OF THIS PROPOSAL FORM

It is your duty to disclose all material information to the underwriters that may affect the premium or conditions. The completed proposal form will form part of your insurance policy with the insurer. Cover is subject to receipt of the original signed proposal form within fourteen (14) days from commencement of cover. Please attach any relevant documents that will assist with your enquiries. Where necessary please continue on a separate sheet.

The policy will be on a claims made basis that means that claims that arise from an incident that occurs during the policy period and provided the claim is notified during the policy period are covered subject to policy terms and conditions.

Please note that this policy covers professional indemnity only and will not cover you for any physical activities, such as sea trials when you are in control of the vessel. A separate policy will be needed, please contact us if you would like a quotation.

1. GENERAL INFORMATION

Company Name (please state if private or plc):
Trading Name (if sole trader):
Partnership Name – (please state if LLP):
Have you previously used a different trading name or company name?      Yes/No  If yes please provide the name and dates as you may require separate “runoff” cover:
Address:
Email:	VAT No:
Business Number:	Mobile:
Fax Number:	Date Company Established:
Website:	Are you a IIMS Member:             Yes / No

Subsidiary Companies and trading names to be named in the insurance policy:

1.

2.

Directors and Senior Managers (Please give full names and qualifications):
Full Name	Qualifications
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2.
3.
4.
5.

(Please provide us with the CV’s of key staff members who will provide the insured services).

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