Professional Indemnity Proposal

Personal Details

Proposer Type

Bank Assurance Officer

Select Intermediary branch

Insurance Company

ID Type

ID Number

KRA Pin

First Name

Middle Name

Last Name

Type of Business

Occupation

Nature of Business

Date Of Birth

Gender

Male Female

Contact Details

Mobile No.

Telephone No.

Email Address

Postal Address

Postal Office

Town

County

Region

Earth Quake Zone

Physical Address

Which FBBI branch do you want to be served from?

Period of Insurance

Cover Start Date

Cover End Date

In which type of profession is the Proposer mainly engaged?

Amount of Indemnity

Limit of liability any one period

Limit of liability rate

Years of experience rate

Apart from the above is there any other professional work which the proposer undertakes?

Does the proposer conduct business from offices other than the above?

Please give the following particulars for each partner / director

What establishment does the proposer maintain to carry on professional work?

Does the proposer engage the services of professionally qualified persons such as Chartered Accountants Engineers etc.

Do you have any other staff?

Name	Designation	Action

Has the Proposer or have the proposers predecessors in the business discharged or is the Proposer contemplating the discharge of any employee for?

Any neglect, act, error or omission?

Any dishonest, fraudulent, criminal or malicious conduct?

Is the proposer now insured against Professional Indemnity Risks?

Has anyone made a claim for breach of professional duty against the Proposer or the Proposer’s predecessors in business or against any partner / director individually or has the Proposer any reason to suspect that such a claim could be made?

Is there any other information material to the risk in the Proposer’s possession?

Do you wish to purchase the following extensions?

Dishonesty of employees

Loss or damage to documents?

Libel and slander

Breach of authority

Incoming and outgoing partners

General Policy Details

Are you now or have you ever been insured for this type of policy ?

Has any insurance company ever

Declined your proposal ?

Cancelled or refused to renew your policy?

Required an increased premium or imposed special conditions?

Declined your claim?

Insurance and Loss History

Please provide below information on any insurance claims you have reported in the last 5 years

Type of loss

Year of Incident

Claim Amount/ Value

Add Loss

DECLARATION | Please Read Carefully *

I/ We do hereby declare that the above answers and statements are true and that I/ We have withheld no material information regarding this proposal. I/ We agree that this declaration and the answers given above as well as any proposal or declaration or statement made in writing by me/ us or anyone acting on my/ our behalf shall form the basis of the contract between me/ us and the Company. I/ We further agree to accept indemnity subject to the conditions in and endorsed on the Company’s policy.

CREDIT INFORMATION | Please Read Carefully *

I/we do hereby confirm that I/we have authorized Family Bank Insurance Agency to share my/our credit information and to access my/our credit profile from Credit Reference Bureau (C.R.B)

Full name	Age	Professional qualification	Date obtained	Years of experience	Action