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Professional Indemnity Insurance Application Form

Application for Insurance Cover

a. Period of Insurance: From [Date] to [Date]

b. Limit of Liability Required

• Option 1: CURRENCY
• Option 2: CURRENCY

c. Excess/Deductible Requested:

• Option 1: CURRENCY
• Option 2: CURRENCY

d. Are you requesting cover for Fraud & Dishonesty? ☐ Yes ☐ No

e. Are you requesting cover for Principals’ Previous Business? ☐ Yes ☐ No

f. Are you requesting cover for Automatic Reinstatement? ☐ Yes ☐ No

g. Are you requesting cover for Cyber and Privacy Infringement Liability?

If YES, Please complete the Questionnaire for Cyber and Privacy Infringement Risk. ☐ Yes ☐ No

Additional Information to Send with Your Application

Attach a copy of the following:

• Corporate profile, brochures, pamphlets, or other marketing material describing your operations and services ☐ Yes ☐ No
• Latest financial statements or annual report ☐ Yes ☐ No
• Standard contracts or service agreements with clients ☐ Yes ☐ No

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