Name of Organisation:
Office Bearer:
Contact Email Address:
Please retype the Contact Email Address here, to reduce the risk
of errors:
Contact Telephone No.:
1.
Does the Charity provide any of the following Professional services:
a) Financial or legal advice?
b) Counselling?
c) Medical advice, diagnosis or treatment?
d) Other kind of advice or information?
2.
a) Give details of type of financial or legal advice provided:
b) How many people provide it?
Part Time:
Full Time:
c) What is the qualification/background/experience of the people
who provide it? (Please supply CV’s if possible)
d) Approximate number of enquiries per annum:
3.
a) Give details of the type of counselling provided:
b) How many people provide it?
Part Time:
Full Time:
c) What is the qualification/background/experience of the people
who provide it? (Please supply CV’s if possible)
d) Approximate number of enquiries per annum:
4.
a) Where counselling or financial or legal advice is provided, give
details of present procedures/guidelines which identify situations where
the person being counselled/advised should be encouraged to seek independent
professional advice:
b) Where such independent advice is appropriate, is it usual practice
to recommend one or more named advisors?
5.
Give details of medical advice, diagnosis or treatment provided:
6.
a) Give full details of other services (e.g. advice, information, assistance,
design) provided:
b) How many people provide it?
Part Time:
Full Time:
c) What is the qualification/background/experience of the people
who provide it? (Please supply CV’s if possible)
d) Approximate number of enquiries per annum:
7.
Standard Limit of Indemnity
£1,000,000
Please indicate amount if an alternative limit is required:
8.
State gross income or total turnover:
Forthcoming Year (estimated):
Last Year:
Previous Year:
9.
a) Has any claim been made against the Proposer or any predecessors
in business or any trustee, director, consultant, or employee for neglect,
error or omission in relation to professional duties?
If Yes give details below.
Date(s) of claim(s) or loss(es) [dd/mm/yyyy]:
Brief details of each claim or loss:
Cost (if any) of claim paid or loss incurred:
Estimated outstanding cost:
b) What action has been taken to prevent the recurrence of the situation
which gave rise to the claim or loss?
10. Is any trustee, principal, director, consultant or employee after
enquiry , aware of any circumstances which might:
a) give rise to a claim against the Proposer or any predecessors in
the business or any of the present or former trustees or principals?
b) result in the Proposer or any predecessors in the business or any
of the present or former trustees or principals incurring any losses or
expenses which might be within the terms of this cover?
c) otherwise affect the Company’s consideration of this insurance?
If YES (for any of 10 a, b or c) give details, including maximum
potential cost
details:
maximum potential cost:
Please check the wording of this
Proposal and the data you have entered carefully before proceeding by
clicking on the 'continue to next stage: final check' button, below.
Clicking on the button will not submit your details yet, but
will cause another page to load.
The new page that loads will give you a chance to check your data again,
and if you need it you will get another opportunity to make changes
before finally sending the data.
If you notice an error shortly after sending the data (when you see
the page that invites you to print the submitted data out for your records)
you can resubmit a corrected version. After submitting, you can try
using your browser's Back button to return to the form. If you are lucky,
the data might still be displayed, which would save you typing it all
in again.
If you resubmit in this way, please also indicate this here:
Are you resubmitting this form after
making a change to a recent submission?
If you only notice an error later
and it's too late to go back and resubmit, or you find that the data
has disappeared from the form when you return to it, please make a copy
of your printed record and fax it to us along with an indication of
the change(s) you wish to make.
Alternatively, please call us on (0131) 225 6005 and
explain the change(s) you would like us to make for you.
Please
note that in such circumstances we may have to send you a form to fill
in on paper and sign in order to confirm changes.
DECLARATION
I,
For the purposes of confirmation, please repeat
your full name here:
Date:
