Computer Consultants Professional Indemnity Insurance Proposal Form
Notes for Professional Indemnity Insurance Proposers:
The Proposal Form, if accepted, will form the basis of your contract with Insurers and it is, therefore, essential that the questions asked have been understood and answered correctly. If in answering any of the questions in this Proposal Form you find there is insufficient space, please complete on your firm’s headed notepaper and attach it to this form.
In the event that you require any assistance in completing this Proposal Form, please do not hesitate to contact
Simon Poon Agency. Please provide, in addition to completing this form, the following information to assist Insurers in considering their terms:
a) Principals’ curriculum vitae. b) Standard Contract Terms and Conditions. c) Copies of any brochures that the Firm issue.

A softcopy of porposal form also available at the following link:-
http://docs.google.com/viewer?a=v&pid=sites&srcid=c2ltb25wb29uYWdlbmN5Lm5ldHx3d3d8Z3g6Mjk 4OTQ4NTRhOGEzNjFiNA
1. Trading names and styles and all addresses of the Companies and/or Partnerships and/or Sole Proprietors (hereinafter referred to as the “Firm”):
2. Please list below details of all Principals and Senior Technical Staff:
Name: Qualifications: Years in the Industry:
3. Please provide the total number of personnel in the following categories: a) Directors, Partners or Sole Practitioner:
3. Please provide the total number of personnel in the following categories: b) Managers:
3. Please provide the total number of personnel in the following categories: c) Technical Personnel:
3. Please provide the total number of personnel in the following categories: d) Support Personnel:
3. Please provide the total number of personnel in the following categories: e) Sales and Marketing:
4. Does the Firm use independent sub-contractors?
4. Does the Firm use independent sub-contractors? If yes, a) What approximate percentage of the Firm’s turnover will be paid to sub-contractors: %
4. Does the Firm use independent sub-contractors? If yes, b) Please provide details of the work that sub-contractors are required to undertake.
4. Does the Firm use independent sub-contractors? If yes, c) How does the Firm select and manage sub-contractors?
4. Does the Firm use independent sub-contractors? If yes, d) Does the Firm ensure that sub-contractors have their own Professional Indemnity insurance?
5. Please provide details of the Firm’s turnover, including fee income: a) Total turnover, including fee income, for the past financial year?
5. Please provide details of the Firm’s turnover, including fee income: b) Estimated turnover, including fee income, for the current financial year?
5. Please provide details of the Firm’s turnover, including fee income: c) Estimated turnover, including fee income, for the next financial year?
5.d) When does the Firm’s financial year end?
5.e) What percentage of the Firm’s turnover, including fee income, is derived from clients domiciled in Malaysia? %
5.f) What percentage of the Firm’s turnover, including fee income, is derived from clients in the United States of America and/or Canada? %
5.g) What percentage of the Firm’s activities as disclosed in question 5.f) above are subject to the laws of the United States of America and/or Canada? %
5.h) What percentage of the Firm’s turnover, including fee income, is derived from clients domiciled elsewhere in the World except the United State of America or/and Canada??
6. Please provide details of the Firm’s five largest contracts carried out in the past five years:
Start Date: Completion Date: Business of Client: Nature of Contract: Contract Value: Firm’s Fee:
7. Please provide details of the Firm’s turnover, including fee income, for the past financial year, split between the following categories (for new Firms please provide an estimate): a) Hardware: i) Sales of own brand:
RM
7. Please provide details of the Firm’s turnover, including fee income, for the past financial year, split between the following categories (for new Firms please provide an estimate): a) ii) Distribution of other brands:
RM
7. Please provide details of the Firm’s turnover, including fee income, for the past financial year, split between the following categories (for new Firms please provide an estimate): a) Hardware: iii) Installation:
RM
7. Please provide details of the Firm’s turnover, including fee income, for the past financial year, split between the following categories (for new Firms please provide an estimate): a) Hardware: iv) Maintenance :
RM
7. b) Software Product Sales: i) Shrink wrapped and/or off the shelf software:
RM
7. b) Software Product Sales: ii) Customisable software:
RM
7. c) Software Services: i) Installation including configuration (no code changes):
RM
7. c) Software Services: ii) Customisation (including code changes):
RM
7. c) Software Services: Iii) Developing bespoke applications:
RM
7. c) Software Services: iv) Maintenance
RM
7. d) Services: i) Consultancy:
RM
7. d) Services: ii) Contract Staff:
RM
7. d) Services: iii) Facilities Management:
RM
7. d) Services: iv) Training:
RM
7. d) Services: v) Contract Programming:
RM
7. d) Services: vi) Internet Services:
RM
7. d) Services: vii) Systems Integration:
RM
7. e) Any other activities (please provide details):
RM
7. f) Will the split of the Firm’s activities change in the current, or coming, financial year? Yes / No If Yes, please provide details:
7. g) Please give a brief description of what the Firm regards as their speciality within the industry:
8. If the Firm carry out any activities in the following areas please provide details: a) Software Installation, including Configuration and Customisation Services (including code changes): i) How long is a typical installation?
8. If the Firm carry out any activities in the following areas please provide details: a) Software Installation, including Configuration and Customisation Services (including code changes): ii) What percentage of the Firm’s clients has their own in house IT expertise? %
8. If the Firm carry out any activities in the following areas please provide details: a) Software Installation, including Configuration and Customisation Services (including code changes): iii) How often does the Firm specify the business requirements for their client and also implement the solutions?
8. If the Firm carry out any activities in the following areas please provide details: b) Bespoke Development Services and Consultancy Services: i) How often does the Firm specify the business requirements for their client and also implement the solution?
8. If the Firm carry out any activities in the following areas please provide details: ii) How often is the Firm given authority to manage project on behalf of their clients?
9. Is the failure of any of the Firm’s products or services liable to result in any of the following outcomes? a) Loss of life or injury to any person? Yes / No
9. Is the failure of any of the Firm’s products or services liable to result in any of the following outcomes? b) Destruction or damage to physical property? Yes / No
9. Is the failure of any of the Firm’s products or services liable to result in any of the following outcomes? c) Immediate and large financial loss? Yes / No
9. Is the failure of any of the Firm’s products or services liable to result in any of the following outcomes? d) Significant cumulative financial loss? Yes / No
9. Is the failure of any of the Firm’s products or services liable to result in any of the following outcomes? e) Insignificant financial loss (i.e. more of a nuisance)? Yes / No
9. If you have answered Yes to any of the above, please provide details:
10. Does the Firm only carry out their activities under their standard Contract Terms and Conditions? Yes / No If No, please provide details:
11. Does the Firm currently have Professional Indemnity Insurance? Yes / No If yes please provide the following information:
11. Does the Firm currently have Professional Indemnity Insurance? a) Name of the Insurer:
11. Does the Firm currently have Professional Indemnity Insurance? b) Renewal Date:
11. Does the Firm currently have Professional Indemnity Insurance? c) Limit of Indemnity:
11. Does the Firm currently have Professional Indemnity Insurance? d) Excess:
11. Does the Firm currently have Professional Indemnity Insurance? e) Premium:
11. Does the Firm currently have Professional Indemnity Insurance? f) Retroactive Date:
12. Has any claim, or potential claim, been made against the Firm, their predecessors in business or any past or present Director, Partner or Principals of the Firm? Yes / No If Yes, please provide full details, including the amounts paid and outstanding:
13. Is any Director, Partner or Principal aware, after enquiry, of any circumstance that may result in a claim being made against the Firm, their predecessors in business, or any past or present Directors, Partners, Principals or Employees of the Firm? Yes / No If Yes, please provide full details:
14. Has the Firm been involved in any dispute or arbitration concerning fees, products, services or intellectual property rights? Yes / No If Yes, please provide full details:
15. In respect of any Insurance, has any Insurer ever declined a proposal or renewal, imposed special terms, cancelled or avoided an insurance policy? Yes / No If Yes, please provide full details:
16. What limits of indemnity would you like quotations for?
Limit 1) Limit 2) Limit 3) (RM)
Declaration
I / We declare that this proposal has been completed, after appropriate enquiry, and that the
statements and particulars in this proposal (including any attachments) are true and that I / we
have neither misrepresented or suppressed any material facts.
I / We undertake to inform Insurers of any material alteration to these facts whether occurring
before or after the completion of the contract of insurance.
I/ We agree that this proposal (including any attachments) is incorporated into and forms the
basis of any contract of insurance.
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Signature of Director, Partner or Principal:
Name of Signatory:
Date:
Note: Please remember to keep a copy of this completed Proposal Form for your records.
By signing this Application Form (or returning it to us if from the website) you consent to us holding and processing your personal data for the above purposes. You also consent to us transferring your information to countries outside the EEA. If we do make such a transfer we will ensure your information is protected. The data controller is Simon Poon Agency. In compliance with the Data Protection Act 1998, we will hold the data, together with other information, securely and confidentially and process it for the purpose of carrying out our activities. These activities are administration, research, marketing and prospecting, accounts and records, insurance broking, risk assessment, consultancy services, surety, and compliance services. If you provide data on another individual within your business, you confirm that you have the consent of that individual to forward the data to us and we will process the data as above. We will process the data about buyers, debtors and debts in accordance with the data protection policy stipulated by the client, which remains the data controller of those data. The client will make its data protection policy clearly known and available to Simon Poon Agency. Where no data protection policy is made known we shall not be liable for any breach under the client’s data protection policy. Furthermore you agree to comply with the Data Protection Act 1998 and to process all personal data in accordance with that Act. We may keep your information for a reasonable period for the on-going pursuance of our business activities as stated above. We may also use the data you provide to contact you by mail, telephone, fax or email with information about our other products and services. A copy of the data we hold on you may be obtained for a small fee upon written request to: The Compliance Officer, Simon Poon Agency, 48-A, Jalan Hujan Rahmat Dua, Taman OUG, 58200 Kuala Lumpur, Malaysia. Simon Poon Agency is regulated by the Financial Services Authority for the conduct of Malaysian business.
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