Fields marked * are required
1. YOUR BUSINESS
Proposer's Name (in full) :
Tel :
Fax :
*Email Address :
When was your business established?
Business Address :
 
 
 
Postcode:
 
2. ASSOCIATED AND SUBSIDIARY COMPANIES
  

We can extend this insurance to include associated and subsidiary companies provided that they are listed below or on a separate sheet and all the information you give in this proposal form relates to all the companies named.
 
Name :
Tel :
Fax :
Email Address :
 
Address :
 
 
Postcode :

 
Name :
Tel :
Fax :
Email Address :

 
Address :
 
 
Postcode :

Have you ever conducted business with any other company with which you have a financial or managerial connection?
Yes
No
If YES, please give full details:
3. YOU AND/OR YOUR PARTNERS & DIRECTORS
Please list below your details and those of any partners or directors of the companies listed above:
Name
Qualifications
Years in the
Industry
Where a partner or director has been working in the relevant industry for less than 5 years please send us their brief CV along with this proposal form.
4. OTHER EMPLOYEES
Please provide the total number of:
Creative staff :
Other technical staff :
Administrative and secretarial staff :
5. SUB CONTRACTORS  
Do you use independent sub-contractors?
Yes
No
If YES:  
a)
 What approximate percentage of your turnover is paid to sub-contractors?
b)
 For which work are they used?


c)
Do you ensure they have their own P.I. insurance?

Yes
No
6. MEMBERSHIP OF PROFESSIONAL ORGANISATIONS
Is your business a member of any professional organisations or trade association?

Yes
No
If YES, please give details below:  
7. YOUR TURNOVER
We need to know your turnover including fee income and where it comes from.
Please fill out the table below:
 
Past Year ending / /
Current Year
Estimate for
coming Year
Total Turnover Including Fee Income
Estimated percentage split of your turnover including fee income for:
Work carried out for UK clients
%
%
%
Work carried out for Overseas clients excluding USA/Canada
%
%
%
Work carried out for USA/Canada clients subject to non USA/Canada law
%
%
%
Work carried out for USA/Canada clients under a contract subject to USA/Canada law
%
%
%
8. CONTRACTS
Please give details of the five largest contracts you have carried out in the past three years:
Name of client
Nature of business
Total value of contract
Income to you from the contract
1.
2.
3.
4.
5.

Within the past three years what is the average value of the contracts you get involved in?
9. YOUR BUSINESS ACTIVITY
Your turnover including fee income must be separated approximately into the activities listed below so that we can understand what you are doing and because we only cover you for the work which you declare:
a) Commercial TV
 
i)
Production of advertisements
ii)
Media spend (whether purchased by you or by a media independent relative to your creative work)
b) Other Media
 
i)
Production of advertisements
ii)
Media spend (whether purchased by you or by a media independent relative to your creative work)
c) Printed Literature/Documents
d) Direct Marketing
i)
Mail shots
ii)
Postage costs
iii)
Telemarketing
iv)
Database Management and List Broking
e) Sales Promotion
f) Marketing (Including all Market Research) Fees
    Production costs
   
g) Public Relations Fees
    Production costs
   
h) Human Resources Fees
i) Specialist Design (NB this insurance is not normally suitable for Interior or Product Designers)
i)
 Graphic Design Fees
    Production costs
   
ii)
 Corporate Identity Fees
    Production costs
   
j) Others. Please specify:  


Does the above split accurately reflect:  
i)
 your business activities in the past?
Yes
No
ii)
 your estimated business activities during the coming year?
Yes
No
  If NO to either of the above, please explain the differences:
10. YOUR WORLD WIDE WEB SITE
a) Do you have your own Web Site?
Yes
No
b) What is your Web Site address?
c) Do you have any facility within your Web Site for any third party to register comments or leave any messages or questions?
Yes
No
If YES, please give details:

  
11. CURRENT INSURANCE
Do you currently have Professional Indemnity insurance?
Yes
No
If YES, what is the renewal date?
If you currently have Professional Indemnity insurance with someone other than Mill Hall then please answer the following:
Name of insurer:
Limit of indemnity:
Excess:
Premium:
12. CLAIMS DECLARATION
a) Has any claim been brought against you arising out of the performance of your business activities or has anyone threatened to bring such a claim?
Yes
No
  If YES, please provide full details:


b) Are you aware of any shortcoming in your work which may lead to a claim against you in the future? This includes a shortcoming known to you but not your client, a complaint from your client about your work even though you may regard it as unjustifiable or the refusal by a client to pay any amount owed to you.

Yes
No
  If YES, please provide full details:  


c) Have you suffered any loss from the dishonesty or malice of any employee, subcontractor or self-employed freelancer?
Yes
No
  Do you currently have any grounds for suspecting that such a person has acted dishonestly or maliciously when working for you or on your behalf?

Yes
No
  If YES to either, please provide full details:  


d) Has any one ever successfully damaged or altered your World Wide Web Site or have you ever suffered any loss due to the authorised contents of your Web Site?

Yes
No
  If YES, please provide full details:  
MATERIAL INFORMATION
Please provide us with details of any other information which may be relevant to our consideration of your proposal for insurance. If you have any doubt over whether something is relevant, please let us have details:
DECLARATION  
1. I/We declare that (a) this proposal form has been completed after proper enquiry; (b) its contents are true and accurate and (c) all facts and matters which may be relevant to the consideration of our proposal for insurance have been disclosed.
2. I/We undertake to inform you before any contract of insurance is concluded, if there is any material change to the information already provided or any new fact or matter arises which may be relevant to the consideration of our proposal for insurance.
3. I/We agree that this proposal form and all other written information which is provided are incorporated into and form the basis of any contract of insurance.
Signature of Principal/Partner/Director :
Date :

Submit Form via web or print and fax to 01268 779050.
Designed and maintained by the webteam@hidenseek.co.uk