PROPOSAL FORM FOR PROFESSIONAL INDEMNITY INSURANCE DownLoad Proposal Form   Personal Information Full Name Head Office Adress Other offices Profession   General Information Of which Professional Association or Body are you a Fellow, Associate or Member? State the Class of your Membership How long have you established in this profession? Do you act as Underwriting Agents for Syndicate,Underwriters or Insurance Companies? Yes No If yes give Details Give the Following Details Name of Partner/Principal Qualification Date Qualified Have you previously held or do you now hold Professional Indemnity Policy? Yes No If Yes give details Has any application or renewal for this type or Indemnity been? Declined? Yes No Subject to increase premium? Yes No Subject to special restrictions? Yes No If Yes please give details Is there any claim outstanding or any circumstances which might give rise to a claim against this practice? Amount of Indemnity Required =N= Does this Practice or any Partner/Principal act in any capacity other than as the Profession stated earlier? Yes No If Yes give details Do you undertake work in any other country outside Nigeria? Yes No If Yes give details Period for which this Indemnity is required? I/We hereby declare and agree that: statements and particulars in this proposal are true and that I/We have not mis-stated or supressed any material facts. I/We agree that this proposal,toghether with any other information supplied by us/me shall form the basis of any contract of insurance effected thereon I/We undertake to inform the Company of any material alteration to these facts wether occuring before or after completion of a contract of insurance. I Disagree I Agree