Insurance Quotation

Please complete this short Statement of Facts to receive your individual insurance quotation.

Statement of Facts

In deciding whether to accept the insurance and in setting the terms and premium, we will have relied on the information you have given us. You must:

give a fair presentation of the risk to be insured. A fair presentation is one which clearly discloses all material facts and circumstances (whether or not subject to a specific question) which you, your senior management and those responsible for arranging this insurance, know or ought to know following a reasonable search;
take care by ensuring that all information provided is correct, accurate and complete.

A material fact or circumstance is one which is likely to influence the insurer’s acceptance or assessment of this proposal. If you are in any doubt as to what constitutes a material fact or circumstance please speak with us.

1. Your Contact DetailsEdit
- Title
- First Name
- Last Name
- Job title
- Telephone number
- Email address
Next
2. Your companyEdit
- Company name
- Address line 1
- Address line 2
- Town/City
- County
- Postcode
- Country
- When was the company established?
- Your company’s website address
  
  E.g. www.example.com
- Total turnover - last full financial year:
  
  Please enter numbers only.
- Total turnover - current projected financial year:
  
  Please enter numbers only.
- Total turnover - next full projected financial year:
  
  Please enter numbers only.
- Total number of directors, partners, members and employees:
  
  Please enter numbers only.
Next
3. Business activitiesEdit
- Business activity
- Other business activity
- The professional indemnity policy will cover you for your disclosed business activity. Please provide a full description of your business activity for which you require cover
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4. Statement of FactsEdit
- By completing this Statement of Facts you confirm these facts whether provided by you or anyone else on your behalf provided are accurate.
  You must read this document to ensure that all the facts stated below are accurate and complete. If any of the facts stated below or any of the information provided to us is not correct or needs to be changed, you must tell us before the start of the period of insurance.
  If there are changes to this information during the period of insurance you must tell us. When we are notified of a change we will tell you if this affects your policy. If you do not inform us about a change it may affect any claim you make or could result in your insurance being invalid.
  Please agree or disagree with the following points (note, when we say "you", we refer to the proposed insured company"):
- You are a UK-registered company/LLP/partnership and have no operations outside the UK.
  - No
  - Yes
- You are either an appointed representative or directly authorised and regulated by the FCA
  - No
  - Yes
- You are acting in accordance with your Minimum Capital Requirements as defined by the FCA.
  - No
  - Yes
- The majority of your customers are either UK or European domiciled and no more than 20% of your total revenue is derived from North American domiciled customers.
  - No
  - Yes
- You do not enter into agreements which are subject to the jurisdiction of the US/Canadian courts.
  - No
  - Yes
- You perform pre-employment reference checks for all employees.
  - No
  - Yes
- You do not authorise any Director/Partner/Employee to sign cheques or make bank transfers on their sole signature in respect of client accounts.
  - No
  - Yes
- You do not undertake any of the regulated activities listed in the Financial Services & Markets Act 2000 (Regulated Activities) Order 2001 in relation to retail investors.
  - No
  - Yes
- Your shares are not listed on any stock exchange.
  - No
  - Yes
- You do not hold more than 20,000 customer records for payment card data, individual tax payer/NI data, drivers’ licence/passport details or financial accounts.
  - No
  - Yes
- All customer records with sensitive data are encrypted, including but not limited to those held on your network, in transit, outside of your network, mobile computing devices or portable storage media.
  - No
  - Yes
- Please provide further information for the questions that you answered no to:
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5. Cover RequirementsEdit
- Please advise the limit of indemnity for which you require a quotation by ticking the relevant boxes. If you would like us to provide options e.g. £1m and £2m, then please choose £specify and put the options you require in the freetype box.
- Professional Indemnity
  - £500,000
  - £1m
  - £2m
  - £specify
- Please specify the limit you require
- Directors’ & Officers’ Liability
  - not required
  - £500,000
  - £1m
  - £2m
  - £specify
- Please specify the limit you require
- Cyber & Data Risks (£50,000 cover is provided when both Professional Indemnity and Directors’ & Officers’ Liability are purchased). Please select if you would like a quotation for a higher limit
  - not required
  - £100,000
  - £250,000
  - £500,000
  - £specify
- Please specify the limit you require
- Crime
  - not required
  - £500,000
  - £1m
  - £2m
  - £specify
- Please specify the limit you require
- Would you like to extend this policy to include:
- Office Contents
  - No
  - Yes
- Office contents sum insured
- Employers’ Liability
  - No
  - Yes
- Number of employees
- Annual wageroll
- Public Liability
  - No
  - Yes
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6. Claims ExperienceEdit
- In the last ten years have there been any claims or investigations made against you, your directors, partners, members, officers or employees.
  - No
  - Yes
- In the last ten years have there been any losses sustained by you; which may have been covered by this insurance had it been in force.
  - No
  - Yes
- Can you please provide further information in respect of each claim, investigation or loss:
  
  1) Date
  
  2) Brief description of the nature of the claim, investigation or loss
  
  3) Values of any payments made or current estimate of loss
  
  4) Measures taken to prevent a reoccurence
- Claim Description
- Claim Description File Help
  
  .zip or .pdf extensions only. Max allowed size is 10MB.
Next
7. DeclarationEdit
- Material information
  Please provide us with any information which may be relevant to our consideration of your proposal for insurance. If you have doubt over whether something is relevant, please let us have details .
  Your information
  Here at Protean Risk we take your privacy seriously and will only use your personal information to provide your insurance quotation and for our legitimate business interests. Click here to learn more about these interests and when we may process your information in this way.
  We will never share, rent or pass your information to any third parties other than insurance companies quoting for and providing your insurance and only then when you have specifically instructed us to seek insurance terms or obtain insurance cover on your behalf.
  Next steps
  We will provide a quotation based on your responses, but we will require some additional information in order to put the insurance in place and this could include:
  1. Business plan
  2. Biographies of directors, partners, professional and trading employees
  3. Latest report and accounts, if applicable
  4. Fund performance report, if applicable
  5. Further specific questions related to your Business Activities.
  The exact requirements will be outlined along with our quotation.
- I/we confirm that the information given in this proposal form is correct, accurate and complete and I have made a fair presentation of the risk
- I agree to your Terms & Conditions and the use of my personal information as explained in your Privacy Policy
- Signature
  
  Please enter your initials.
By submitting this form you are confirming all details are correct and this form is complete.
Submit

Need help?

T: 020 3763 5340
E: info@proteanrisk.com

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