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a.     Name of person to whom correspondence should be addressed:

b.     Please provide us with the number of:

Partners, Directors and Senior Managers:
Qualified (field) Staff:
Clerical Staff:
Total:

c.     Please give details of any trade association to which you are a member:

 

2. BUSINESS ACTIVITIES

a.           Please indicate your Gross Annual Income (fees only) and currency:

Gross Annual Income: (this is only income derived from the activities for which you wish to be insured)

Currency: 
Annual Income Last Financial Year:
Annual Income Estimate for this Financial Year:
Annual Income Estimate for next Financial Year:

b. You must describe in detail all the services for which insurance cover is required and attach a separate sheet if necessary.  Please note that normally third party liability cover (public liability cover) is only provided if you are covered for professional indemnity losses arising from the service you are undertaking therefore if you exclude a service you undertake from the professional indemnity cover section you would have no third party liability cover whilst undertaking that service.

c.     Do you perform and/or provide any of the following (Please also indicate the estimated percentage (%) gross annual income derived from each activity):

	Please circle as necessary	% of Annual Turnover
Pre-purchase or condition surveys of yachts or pleasure crafts	Yes/No
Gas free certificates	Yes/No
Quality or quantity surveys	Yes/No
Cargo hold inspections	Yes/No
Insurance Condition surveys	Yes/No
Others please specify

d. Please name any principals for whom you regularly act:

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