Date of commencement of Practice:
Names and Qualifications of Principals (attach ID copies below)
If yes, please provide the following details:
4.2. For the type of Insurance now being proposed, has any Insurer ever:
Total Number of:
6.7. Please provide any other information which may be relevant to Insurers understanding of the insurance being proposed for e.g. but not limited to:
As at the company’s financial year end.
Please give the audited fees for the past 5 years:
Specific nature of cover being proposed for and indemnity limit.
I/We the undersigned duly authorised person(s) declare that:
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