Coverholder at

OBF Insurance Group Ltd. is regulated by the Central Bank of Ireland. Registered in Ireland No. 39988. Brokers Ireland Member.

OBF Insurance Group Ltd. Bridge House, Baggot Street Bridge, Dublin 4. D04 X2P1T: +353 1 660 1033 / 676 0201 | F: +353 1 668 7985 | E: piteam@obf.ie | W: www.obf.ie

SURVEYORSPROFESSIONAL INDEMNITYPROPOSAL FORM

– 2 – Surveyors PI Proposal form

Please Note:

• Thisisisaproposalforacontractofinsurance,inwhich‘proposer’or‘you/your’meanstheindividual,company, partnership, limited liability partnership, organisation or association proposing cover.

• ThisisaproposalformforapolicyrelatingtoclaimsmadeagainsttheInsuredduringtheperiodofthepolicy only – CLAIMS MADE.

• Pleaseanswerallthequestionsgivingfullandcompleteanswers.Pleaseuseaseparatesheetofpaperif there is insufficient space. If necessary please write additional relevant facts on a separate sheet of paper.

• Theproposalformmustbecompleted,signedanddatedbyapersonwhoisoflegalcapacityandhastheauthorisationtorequestthisinsurancefortheProposer.

• ThisformdoesnotbindtheProposerbutwillformpartoftheInsurancecontractiftakenup.

• Allmaterialfactsmustbedisclosed,asfailuretodosomayrenderanypolicyorcertificatevoidable,or severely prejudice your rights in the event of any claim. A material fact is one likely to influence acceptance or assessment of the proposal by Underwriters. If you are in doubt as to what constitutes a material fact, you should consult your broker.

Please supply the following additional information:

• CompanyBrochure

• CVsofPrincipals

• CopyofStandardContractTermsandConditions(ifapplicable)

– 3 – Surveyors PI Proposal form

DETAILS OF THE PROPOSER

1. Name(s)(includingtradingnames/subsidiarycompanies)ofallentitiestobeInsured:

2. Main Address:

3. Website:

4. Email address:

5. Phone No: 6. Establishment Date of Firm

7. Please state total number of: Principals/Partners/Directors: Other Technical Staff:

QualifiedStaff: Administrative/Other:

8. a)DetailsofallDirectors/Partners/Principals:

Partners/Principals Qualifications Date QualifiedHow long a Director, Partner, Principal ofthis firm/company

9. a)HastheNameoftheProposereverbeenchanged? Yes No

b)Hasanyotherpracticeorbusinessamalgamatedormergedwithyou? Yes No

c)Haveyoupurchasedanyotherpracticeorbusiness? Yes No IfYes,pleaseprovidefulldetails:

10. IscoverrequiredforanyPartner’sLiabilitypriortojoiningthefirm? Yes No IfYes,pleaseprovideNameofPartner,NameofPreviousFirmandDateat whichthePartnerjoinedtheabovefirm:

11. If the Proposer is a sole practitioner, what procedures are in place for periods of absence from the office or illness?Pleaseprovidefulldetails:

– 4 – Surveyors PI Proposal form

12. Please list the professional, regulatory bodies, trade associations or societies to which you belong:

13. Please give the name and experience of any person carrying out structural surveys and/or valuation Reports who is not a Fellow of Associate of the Royal Institute of Chartered Surveyors or a Fellow or Associate of the IncorporatedSocietyofValuersandAuctioneers,orRoyalInstituteofBritishArchitectsorFellowoftheFacultyofSurveyors(oritsequivalentinIreland):

14. a)Arewrittenreferencesobtainedinrespectofnewemployees? Yes No b)IsanyPartner/DirectororEmployeeallowedtosignchequesonhis/her signaturealone? Yes No

IfYes,uptowhatamount? €

c)HowoftenaretheentriesontheCashBookreconciledagainsttheBank Statementsbyaseniorperson,otherthantheheadbookkeeper?

d)Hastheproposereversustainedanylossthroughfraudordishonestyof anyemployee? Yes No

IfYes,pleaseprovidefulldetails:

– 5 – Surveyors PI Proposal form

2. a)Pleaseprovideapercentagesplitofyourincomebygeographicalarea:

% of Gross Fees

DomesticContracts(Ireland)

UK Contracts

EU Contracts

USA/Canada(SubjecttononUSA/CanadaLaw)

USA/Canada(SubjecttoUSA/CanadaLaw)

Rest of the World Contracts

3. a)PleaseconfirmthepercentagesplitofyourincomebygeographicalareainIreland:

Area %

b)Ifother,pleasespecifyarea(s)/country(s)andcorrespondingpercentageofyourincome:

Area %

4. Whatpercentageofyourgrossfeeswasderivedinthepreviousfinancialyear fromyourlargestclient?

5. Pleaselisttheproposer’ssixlargestcontractsinthelastfiveyears:

Client Territory Description of Professional Services

Total Contract

Value

YourFees

Start Date

End Date

DETAILS OF ACTIVITIES/INCOME/FEES

1. a)Pleaseprovidethedetailsofyourgrossfees:

Last Financial Year Current Financial Year Estimate for Next Financial Year

Gross Fee

Maximum Fee

Average Fee

b)FinancialYearEnd:

/ // // /

– 6 – Surveyors PI Proposal form

6. Pleaseprovideasplitofgrossfeesinthepreviousfinancialyear::

Activity %Quantity Surveying

Building Surveying

Land/Mineral/Hydrographic Surveying

ResidentialSurveys/ValuationsforLendingpurposes

OtherResidentialSurveys/Valuations

CommercialSurveys/ValuationsforLendingPurposes

OtherCommercialSurveys/Valuations

Planning & Development Consultancy

ProjectCo-Ordination(whereyouhaveNoresponsibilityforappointmentofotherconsultants/contractors)

ProjectManagement(whereyouhaveresponsibilityforappointmentofotherconsultants/contractors)

Architectural

Environmental

Residential Property Management

Commercial Property/Land Management

Rent Reviews/Lease Renewals

Residential Estate Agency

Commercial Estate Agency

Auctioneering – Livestock

Auctioneering – Other

Building Society Agency

General Insurance Business

Financial Services

Loss Assessing and Adjusting

Other Work – Please provide full details on a separate sheet

TOTAL 100%

7. If you have ceased to provide any of the services detailed in Question 6 above in the last three years, please confirmthenatureofservicesprovidedandthefeesderivedfromthisactivity(ies):

8. Please provide further information about the work you have undertaken in the past for the following activities: a)QuantitySurveying:

Averagetotalcontractvalueinthelast3years: €

Highesttotalindividualcontractvalueinthelast3years: €

b)ResidentialSurveys/ValuationsforLendingPurposes.Forthelast3yearspleaseconfirm:

Average annual number of reports

Highestsinglepropertyvaluation: €

AverageValuation: €

– 7 – Surveyors PI Proposal form

Please identify your 3 largest clients:

Name Annual Fee Income - €

c)CommercialSurveys/ValuationsforLendingPurposes:

Average annual no. of reports

Highestsinglepropertyvaluation: €

Highestsinglepropertyvaluation: €

AverageValuation: €

Please identify your 3 largest clients:

Name Annual Fee Income - €

d)OtherCommercialSurveys/Valuations:

For the last 3 years please provide details of your 3 largest valuations:

Valuation Client Purpose

e)ProjectCo-Ordination: Pleaseconfirmthehighesttotalindividualcontractvalueinthepast3years: €

f )ProjectManagement: Pleaseconfirmthehighesttotalindividualcontractvalueinthepast3years: €

g)ArchitecturalWork: Please provide details of the 3 largest contracts where construction commended during the last 3 years:

Description Extent of Service (full etc.)Total

Contract ValueApprox.

Completion Date

h)Environmental: Please provide a full description of your activities:

Do you undertake any work which involves polluted or contaminated land or property, or advise third parties as to whether or not land or property may be pollutedorcontaminated? Yes No

– 8 – Surveyors PI Proposal form

IfYes,doyouhaveastandardcontractortermsofengagementwhichincorporates adisclaimerorlimitationofliabilityinrespectofpollutionandcontamination? Yes No

IfYes,pleaseconfirmhowlongthishasbeenused: (Pleaseattachacopy)

i)CommercialProperty/LandManagement(incRentReviewsetc.): Isthereaworkingdiarysystemwhichischeckedregularly? Yes No

j)CommercialEstateAgency: Averageindividualpropertyvaluehandledinthelast3years? €

Highestindividualpropertyvaluehandledinthelast3years? €

k)Auctioneering: Forthelastyearpleaseconfirmthefollowing:

Fees - € Max Value - € Ave Value - €

Livestock & Deadstock

FineArtorAntiques

Property or Land

Other – Please provide details on a separate sheet

l)FinancialServices: DoyouundertakeanyFinancialServicesactivities? Yes No

Areyoutied(forthepurposesoftheFinancialServicesAct)toanyorganisation? Yes No

Ifindependent,howareyouregulated?

m)OtherWork: Please provide full details of any other work you undertake:

9. FORSURVEYANDVALUATIONWORKONLY–IfNONEpleasemarkasN/A N/A

a)Arevaluationsonlyundertakenbyqualifiedvaluers? Yes No b)PleaseconfirmwhoundertakestheSurveys/Valuationsandtheirqualifications (whereapplicable):

c)Doyouhaveanysysteminplaceforthecross-referencingofvaluationsfor similarproperties? Yes No

IfYes,howlonghasthissystembeeninoperation?

IfNo,howwouldyousupporttheaccuracyofanyvaluation?

d)HaveyouatalltimescompliedwiththeRICSManualofValuationGuidance NotesandtheStatementofAssetValuationPracticeandGuidanceNotesand, whenissued,theAppraisalandValuationManual? Yes No

– 9 – Surveyors PI Proposal form

If No, please explain:

10. Doyouuseastandardformofcontract,agreementorletterofappointment? Yes No IfYes,pleaseattachacopy

11. Doyoualwaysconfirmverbalreportsinwriting? Yes No If No, please explain:

12. Do you undertake any work which involves polluted land or property or advise third partiesastowhetherornotlandorpropertymaybepollutedorcontaminated? Yes No

IfYes,doyouhaveastandardcontractortermsofengagementwhichincorporates adisclaimerorlimitationofliabilityinrespectofpollutionorcontamination? Yes No

IfYes,pleaseconfirmhowlongthishasbeenusedandattachacopy:

13. a)Doyouusetheservicesofconsultants,sub-contractorsoragents? Yes No

IfYes,doyourequirethemtocarrytheirownPIInsurance? Yes No

IfYes,towhatlimit?

b)Whatpercentageofyourincomerelatestosub-contractedwork?

14. a)DoesthePrincipals/Partners/Directorsoftheproposerhaveanyassociation withorfinancialinterestinanyotherpractice,companyororganisation? Yes No

IfYes,pleaseprovidefulldetails:

b)Is,orhastheproposerbeenamemberofaconsortium,grouppractice,jointventure,strategicallianceorinvolvedinanysingleprojectpartnership?IfYes,pleaseprovidefulldetails:

NB: Special arrangements must be made with insurers if indemnity is to be granted.

– 10 – Surveyors PI Proposal form

PREVIOUS/CURRENT INSURANCE

1. DoestheProposercurrentlyhaveaProfessionalIndemnityInsurancepolicyinforce?Yes No

IfYes:

a)Insurer

b)ExpiryDate

c)LimitofIndemnity d)Excess

e)Premium

f )ExpiryRetroactiveDate

2. Has any previous policy for Professional Indemnity insurance been cancelled orrefusedorhadanyspecialtermsimposedbyanyinsurer? Yes No

IfYes,pleaseprovidefulldetails:

CLAIMS/CIRCUMSTANCES INFORMATION1. Haveanyclaimsallegingnegligentact,errororomission(successfulorotherwise) been made against you, your predecessors in business, or present or past partners, principalsordirectors? Yes No

IfYes,havesuchmattersbeennotifiedtocurrentorpreviousUnderwriters? Yes No

Please provide full details:

3. PleaseindicatetheLimitofIndemnityrequired:

€500,000 €1,000,000 €1,500,000 €2,000,000 €2,500,000

€3,000,000 €5,000,000

Please specify if other:

4. WhatExcessistheProposerpreparedtocarryuninsured?

€1,000,€2,500,€5,000,€10,000or‘Other’

– 11 – Surveyors PI Proposal form

DATA PROTECTION

OBF Insurance Group Ltd. recognise that protecting personal information including sensitive personal information is very important and we recognise that you have an interest in how we collect, use and share such information. Our DataProtectionPolicyisinlinewiththerequirementsundertheGeneralDataProtectionRegulations(GDPR)whichare effective from 25 May 2018.

Please read the following carefully as it contains important information relating to the information that you give us or has been provided to us on your behalf. If you provide information relating to anyone other than yourself, you are responsible for obtaining their consent to the use of their data in the manner outlined below.

Full details of how we collect, use, store and protect your data can be found in our Data Privacy Notice, a copy of whichisavailableonrequestorviaourwebsite,www.obf.ie.

What does OBF Insurance Group Ltd. do with your personal data?

Information you provide will be used by OBF Insurance Group Ltd. for the purposes of processing your application and administering your insurance policy. OBF Insurance Group Ltd. may need to collect sensitive personal data relating to you(suchasmedicalorhealthrecords)inordertoprocessyourapplicationand/oranyclaimmade.

AllinformationsuppliedbyyouwillbetreatedinconfidencebyOBFInsuranceGroupLtd.andwillnotbedisclosedto any thirdparties except (a) toour agents, sub–contractors and reinsurers (b) to thirdparties involved in theassessment,administrationorinvestigationofaclaim(c)whereyourconsenthasbeenreceivedor(d)tomeetourlegal or regulatory obligations. In order to provide you with products and services this information will be held in the data systems of OBF Insurance Group Ltd. or our agents or subcontractors. The data is held on servers with multiple layers of security. Please note that some servers which may hold your data are located outside the EU.

We will hold data collected from you for the duration of our business relationship with you and for six years after that.ThisisarequirementundertheCentralBank’sConsumerProtectionCode2012.Yourdatamaybeusedforthepurposesofautomateddecisionmakingbutwillnotbeusedforprofilingpurposes.

OBF Insurance Group Ltd. may pass your information to other companies for processing on its behalf. OBF Insurance Group Ltd. will ensure that its transfer of data is lawful and that your information is kept securely and only used for the purpose for which it was provided.

CallstoandfromOBFInsuranceGroupLtd.arerecordedforqualityassuranceorverificationpurposes.

2. Areyouoranypartners,directorsorprincipals,afterhavingmadefullenquires,includingofallstaff,awareofany of the following matters

a)Anycircumstanceswhichmaygiverisetoaclaimagainstyou,yourpredecessors inbusinessoranypastorpresentpartner,directorprincipaloremployees? Yes No

b)Thereceiptofanycomplaints,whetheroralorinwriting,regardingservices performedoradvicegivenbyyou? Yes No

IfYes,pleaseprovidefulldetails:

– 12 – Surveyors PI Proposal form

Your Rights under our Data Protection Policy

Youhavetherightto:

• Accessthedataweholdaboutyou• Havethedataweholdaboutyoutransferredtoanotherpersonororganisation• Haveinaccuratedataaboutyoucorrected• Haveinformationaboutyouerased(thiscouldaffectourabilitytoprocessyourbusiness)• Objecttodirectmarketingfromus• Restricttheprocessingofyourdata(thiscouldaffectourabilitytoprocessyourbusiness)• Makeacomplainttousabouttheimplementationofourdataprotectionpolicyandprocedures.

Toaccessthedataweholdaboutyou,youwillneedtocompleteandsubmitaDataAccessRequestForm,availableonrequestorviaourwebsite.

Data Breaches

In the event of a data breach which results in your personal data being compromised, we will advise the Data Protection Commissioner within 72 hours at most, unless the data was encrypted or anonymised. Were there is a high risk to your rights, as set out in the GDPR, we will also advise you of the details of the breach and the steps we have taken to rectify it and prevent its recurrence.

Fraud Prevention, Detection and Claims History

In order to prevent and detect fraud and the non-disclosure of relevant information OBF Insurance Group Ltd. may at any time:

• ShareinformationaboutyouwithcompaniesororganisationsoutsideOBFInsuranceGroupLtd.includingwhere applicable private investigators and public bodies including An Garda Siochana;

• Checkand/orfileyourdetailswithfraudpreventionagenciesanddatabasessuchasInsuranceLink,andifyougive us false or inaccurate information and we suspect fraud, we will record this. For more information on the functioning of InsuranceLink, please visit insurancelink.ie.

OBF Insurance Group Ltd. may also search these agencies and databases to :

• Helpmake decisions about the provision and administration of insurance, credit and related services for you and members of your household;

• Tracedebtorsorbeneficiaries,recoverdebt,preventfraudandtomanageyouraccountorinsurancepolicies;• Checkyouridentitytopreventmoneylaundering,unlessyoufurnishuswithothersatisfactoryproofofidentity;• Undertake credit searches and additional fraud searches.

DECLARATION

The undersigned authorised Person declares that the statement and particulars in this Proposal form are true and thatnomaterialfactshavebeenmisstatedorsuppressedafterenquiry.Theundersignedagreesthatshouldanyofthe information alter between the date of this Proposal and inception date of the insurance to which this proposal relates, they will give immediate notice thereof. The undersigned agrees that this Proposal, together with any other information supplied by us shall form the basis of any contract of insurance effected thereon.

Signature:

Name:

Position: Date:

1 Names including trading namessubsidiary companies of all entities to be Insured: 2 Main Address: 3 Website: 4 Email address: 5 Phone No: 6 Establishment Date of Firm: PrincipalsPartnersDirectors: Other Technical Staff: Qualified Staff: AdministrativeOther: If Yes please provide full details: which the Partner joined the above firm: illness Please provide full details: 12 Please list the professional regulatory bodies trade associations or societies to which you belong: of Surveyors or its equivalent in Ireland: €: undefined: If Yes please provide full details_2: b Financial Year End: Domestic Contracts Ireland: UK Contracts: EU Contracts: USACanada Subject to non USACanada Law: USACanada Subject to USACanada Law: Rest of the World Contracts: undefined_3: Quantity Surveying: Building Surveying: LandMineralHydrographic Surveying: Residential SurveysValuations for Lending purposes: Other Residential SurveysValuations: Commercial SurveysValuations for Lending Purposes: Other Commercial SurveysValuations: Planning Development Consultancy: Project CoOrdination where you have No responsibility for appointment of other consultantscontractors: Project Management where you have responsibility for appointment of other consultantscontractors: Architectural: Environmental: Residential Property Management: Commercial PropertyLand Management: Rent ReviewsLease Renewals: Residential Estate Agency: Commercial Estate Agency: Auctioneering Livestock: Auctioneering Other: Building Society Agency: General Insurance Business: Financial Services: Loss Assessing and Adjusting: Other Work Please provide full details on a separate sheet: confirm the nature of services provided and the fees derived from this activityies: €_2: €_3: undefined_4: €_4: €_5: undefined_5: €_6: €_7: €_8: €_9: €_10: Please provide a full description of your activities: undefined_6: €_11: €_12: If independent how are you regulated: Please provide full details of any other work you undertake: where applicable: undefined_7: If No how would you support the accuracy of any valuation: If No please explain: If No please explain_2: If Yes please confirm how long this has been used and attach a copy: undefined_8: undefined_9: If Yes please provide full details_3: involved in any single project partnership If Yes please provide full details: undefined_10: undefined_11: undefined_12: undefined_13: undefined_14: f Expiry Retroactive Date: undefined_15: Please specify if other: €1000 €2500 €5000 €10000 or Other: Please provide full details: If Yes please provide full details_4: Name: Position: Date: Text-1: 0: 1: 2: 3: 4:

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