Sourcing form • LSK Risk Management

Company name *

Correspondence address *

Country *

Is your company domiciled in the United Kingdom? *

Yes
No

Is all work carried out within the UK and/or EU? *

Yes
No

Profession/business description *

Projected turnover *

Do all Principals, Partners or Directors have relevant qualifications &/or at least 5 years experience? Yes/No (if no, please advise experience/courses/education)

Does one client make up more than 30% of the Proposers annual income? *

Yes
No
Other

Does the Firm currently hold Professional Indemnity Insurance? (if so, is the policy fully retroactive?) *

Yes
No
Other

Have any of your contracts in the last 5 years or expected in next 12 months exceeded £15 million in value? *

Yes
No

Name *

First

Last

Email *

Contact number *

What limit of Professional indemnity do you require? *

Freetype of above questions explained.

Please initial in the box below to confirm, by completing this form you are providing confirmation that we are able to supply your information to our brokers and insurers in order to retrieve you an insurance quotation. *

Please confirm the following for our due diligence: *

Yes
No

- No claims for professional negligence, error or omissions or the like have ever been made against the - Firm or any predecessor(s) in business or against any Partners / Directors / Principals either directly or in respect of any company of which they were a Partner / Director / Principal of. - After enquiry within the Firm, the Proposer is not aware of any circumstances which have occurred which may give rise to a claim. - The Firm or any Partners / Directors / Principals has not had any insurers decline to offer Professional Indemnity renewal terms, nor has had their Professional Indemnity Policy cancelled or voided, or had any special premium increase or special terms being imposed due to a material fact. - The Firm or any Partners / Directors / Principals do not act, or have not acted, in any capacity other than those declared. - The Firm or any Partners / Directors / Principals have not ever been the subject of investigations or disciplinary proceedings by any regulatory body or the Health & Safety Executive. - The Firm or any Partners / Directors / Principals do not undertake work for any Partnership, Company or Organisation in which they are in a position to exercise a controlling interest in such a Partnership / Company / Organisation. - This company does not provide any investment advice.