Proposal Forms

Company Name:

VAT No.:

Address:

Telephone:

Fax:

E-mail:

Website Address:

Insurance Broker to whom Quotation should be sent:

1. General Information

a)

Date company established:

b)

Name and address of any subsidiary, associated companies or branch offices to be insured:

c)

Please briefly describe the nature of your business:

d)

Total no. of staff employed:

e)

Names, positions, professional qualifications and number of years' experience of Directors/Partners and Senior Managers:

f)

Contact name/e-mail address (if different):

g)

Is the company a member of any Trade Association? Yes No

If Yes, please provide details:

2. Gross Annual Income (fees and commission earned)

Please indicate company's gross annual income (i.e. income from fees and commissions from activities listed in e):

a)

Currency e.g. US$:

b)

Last financial year:

c)

This financial year:

d)

Next financial year:

e)

Percentage of income earned by UK offices (if applicable):

f)

Please categorise your activities and indicate approximate percentage of gross annual income from each (e.g. ship agent 80%; transport consultant 20%):

3. Principals

Please name the principals for whom you regularly act:

Do you have any financial interest in any of your principal's companies?: Yes No

Do your principals have any financial interest in your company?: Yes No

Are you involved in the manufacture, construction, alteration, repair or sale of products other than in a consultancy capacity?: Yes No

If "Yes" - please provide details: †

4. Contract Conditions

a)

Do you enter into any written agreement or operate under a standard form of contract or trading conditions?: Yes No

If "Yes" - please provide details: †

5. Claims History

a)

Have any claims been made against you, or have there been any circumstances likely to give rise to a claim being made against you in the last five years?: Yes No

Has any insurer:

i)

Declined to insure you?: Yes No

ii)

Cancelled your insurance?: Yes No

iii)

Refused to renew your insurance?: Yes No

iv)

Imposed penalties or special terms?: Yes No

6. Limits and Deductibles

Please supply the following information (if currently not insured, please advise the limit of liability and excess/deductible you require):

a)

Name of current insurer:

b)

Limit of liability:

c)

Excess/deductible:

d)

Premium:

e)

Expiry date:

7. Quality assurance

Have you obtained quality assurance accreditation in accordance with BS5750/ISO9000:
(A discount is available if you have) Yes No

8. Additional insurances available from ITIC

Would you like details about loss of commission insurance? Yes No Ship agents' cash in transit and money insurance? Yes No Debt collection for the legal cost of pursuing unpaid disbursements & commission? Yes No Directors' & officers' liability insurance? Yes No

9. Submit

Please send us copies of any literature about your company which is relevant to this proposal. We find it very helpful.

DECLARATION

I/We undertake that if this proposal is accepted I/We will act and abide and agree to be bound by the Rules of ITIC and any modification or alteration thereof made in accordance therewith from time to time and also by the decision of the Club and its Directors.

I/We declare that to the best of my/our knowledge and belief, the information given above is true and that I/We have not suppressed or misstated any material facts. (A material fact is one likely to influence an underwriter's assessment or acceptance of this proposal).

This proposal form must be completed by a person who is authorised to bind their company.

† The total aggregate size of all your attached files should not exceed 1Mb.

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Proposal Forms

Proposal Forms

1. General Information

a)

b)

c)

d)

e)

f)

g)

2. Gross Annual Income (fees and commission earned)

a)

b)

c)

d)

e)

f)

3. Principals

4. Contract Conditions

a)

5. Claims History

a)

i)

ii)

iii)

iv)

6. Limits and Deductibles

a)

b)

c)

d)

e)

7. Quality assurance

8. Additional insurances available from ITIC

9. Submit

DECLARATION