Please complete this form to receive your Directors’ & Officers’ Liability quotation. In deciding whether to accept the insurance and in setting the terms and premium, insurers will have relied on the information you have given us. 

You must:

  • give a fair presentation of the risk to be insured by clearly disclosing all material facts and circumstances (whether or not subject to a specific question) which you, your senior management and those responsible for arranging this insurance, know or ought to know following a reasonable search;
  • take care by ensuring that all information provided is correct, accurate and complete.
  • 1. Your Contact DetailsEdit
  • 2. Your companyEdit
    • E.g.

    • Please enter numbers only.

  • 3. Facts about your businessEdit
    • Please agree (yes) or disagree (no) with the following points (note, when we say "you" or “your” we refer to the proposed insured company):

  • 4. Cover RequirementsEdit
    • Please advise the limit of indemnity for which you require a quotation by ticking the relevant boxes. If you would like us to provide options e.g. £1m and £2m, then please choose £specify and put the options you require in the freetype box.

  • 5. Claims ExperienceEdit
    • Can you please provide further information in respect of each claim, investigation or loss:

      1) Date

      2) Brief description of the nature of the claim, investigation or loss

      3) Values of any payments made or current estimate of loss

      4) Measures taken to prevent a reoccurence

    • Help
  • 6. DeclarationEdit
    • By making this application you confirm that no director, manager, partner or trustee of yours or any person insured or proposing for insurance has:

      • been convicted, or charged but not yet tried, of any criminal offence other than a motoring offence
      • been declared bankrupt, gone into insolvent liquidation, or been the subject of receivership or an administration order

      And that:

      • you have never had an application for this type of insurance declined by an insurer, had a renewal of such insurance declined, or had similar insurance cancelled or made subject to special conditions
      • After enquiry you are not aware of any circumstance or incident which they have reason to suppose might afford grounds for any future claim such as would fall within the scope of the proposed insurance which has not already been advised to us

      Important information concerning your duty to make a fair presentation of risk.

      Please carefully read the following before you sign the declaration.

      Before the insurance policy takes effect you have a duty to make a fair presentation of the risks to be insured.

      A fair presentation of the risk is one

      • which discloses to us every material circumstance which you know of or ought to know of, or
      • gives us sufficient information to put us on notice that we will need to make further enquiries for the purpose of revealing those material circumstances, and
      • which makes that disclosure in a manner which is reasonably clear and accessible to us, and
      • in which every material representation as to a matter of fact is substantially correct and every material representation as to a matter of expectation or belief is made in good faith.

      A material circumstance is one that would influence our decision as to whether or not to agree to insure you and, if so, the terms of that insurance.

      If you are in any doubt as to whether a circumstance is material, you should disclose it to us. Failure to make a fair presentation of risk could prejudice, reduce or modify your rights under the policy.

      I declare that

      • I am authorised to complete this proposal on behalf of the Proposer
      • every statement and particular within this proposal form
        • which is a statement of fact, is substantially correct, and
        • which is a matter of expectation or belief, is made in good faith

      If any such facts, expectations and/or beliefs materially change before the insurance policy takes effect I will undertake to provide details of all such changes to you in order to comply with my obligation to provide a fair presentation of the risk to be insured under the insurance policy.

      Your Information

      Here at Protean Risk we take your privacy seriously and will only use your personal information to provide your Directors’ & Officers’ Liability insurance quotation and for our legitimate business interests.  Click here to learn more about these interests and when we may process your information in this way.

    • Please enter your initials.