Tree Surgery and Forestry Professional Indemnity Enquiry Form

Name*:

(State names of all partners and trading name if not a limited company)

Address Line 1*:

Address Line 2:

Address Line 3:

Postcode*:

Telephone Number*:

Fax Number:

Email Address*:

Web Address:

Current/Previous Insurer or Broker Name:

Renewal Date:

Renewal/Target Premium:

How did you hear about Lycetts?*

How many years experience do you have in this industry?

Please state fully all activities in which you or your firm are involved:

What limit of Indemnity do you require?

What is your estimated annual fee income for consultancy and advice?

Please categorise business activities and indicate the approximate percentage of gross income/fees these represent:

Consultancy work relating to the structural integrity of property and the possibility of subsidence and heave*

Tree hazard evaluation*

Other (please describe below)

Other Description

What ‘Retroactive Date’ is required and has cover been continuous from this date?

Date (DD/MM/YYYY):

Have there been any incidents in the last 5 years, which have, or could have given rise to any claims under this section? If so, please provide details below

Date of Incident:

Incident Description:

Amount Paid/Reserve: