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PROPOSAL FORM FOR PROFESSIONAL INDEMNITY QUESTIONS 1. a. Name and Address(es) of Firm: b. Business or Practice: 2.

2. Full name of each partner, qualifications and when qualified how long practising as a Partner in the Firm. a. b. c. d. e. Name: Qualifications: When Qualified: How long practising as a Partner in the firm Previous Firm(s) 3. Total numbers of Partners and Staff. a. b. Partners Qualified staff

c.

Unqualified staff (other than Kitchen staff, Tea Orderlies and Messengers)..

d. e. 4. 5.

Kitchen staff, Tea Orderlies and Messengers What are the annual fees of Partnership/Firm

When was the Firm established? Does the Firms practise extend or has it ever extended to activities outside Zimbabwe? Yes/No if so, please indicate. a. what percentage this is/was of the Firms total business... and b. method of handling such business. Total indemnity required any one period of insurance (inclusive of any extensions)$... Do you require a higher excess than the Compulsory Excess of 10% of the Indemnity Limit .

6.

a. b.

c. If so, for what amount?.. .

E X T E N S I O N S
(These Extensions are not necessarily available to Firms practising) 7. If available, do the Firm require:Extension 1 Libel and Slander Extension 2 Partners Previous Business (a) Outgoing Partners Extension 3 Breach of Authority Extension 4 Loss of Documents Extension 5 Conversion 8. If Extension 2 (b) (Outgoing Partners) is require please give (a) full names of the former Partners to who it is to apply . (b) dates when they ceased to be Partners in the Firm. 9. Has any application for Insurance of this nature made on behalf of the Firm or their predecessors in business or any of the present Partners ever been declined or has any such Insurance ever been cancelled or refused renewal or have special terms been imposed? If so, please give full particulars. .. . 10. Have any claims ever been made against the Firm or their predecessors in business or any of the present or former Partners? If so, please give full particulars .

11.

Are any of the Partners, after enquiry, aware of any circumstance which is likely to give rise to a claim against the Firm or their predecessors in business or any of the present or former Partners? If so, please give full particulars. . .

12. 13.

Has the Insured or have his predecessors in business discharged or are they contemplating the discharge of any employee of. (a) Any negligent act, error or omission? (b) Any dishonest fraudulent criminal or malicious conduct?

I/We hereby declared that the above statements and particulars are true and that I/we have not suppressed or misstated any material facts and I/we agree that this Proposal Form shall be the basis of the contract with the Underwriters. Name of Firm: By (Partners) Date .

This Proposal Form must be signed by a Partner. Signature of the Form does not bind the Firm or the Underwriters to complete the Insurance.