Insurer Form 1 Details of applicant 2 Professional business 3 General information 4 Income details 5 Employee information 6 Limit of indemnity required Section 1 – Details of applicant Insured Name Address of head office Web Address Date established (dd/mm/yy) Country / State of Registration ABN / ACN Telephone No. Address of all other locations (if any) from which the Insured operates Previous Next Section 2 – Professional business Please provide a detailed description of your professional business which is required to be covered by this Policy. You should attach any brochures or promotional material that may provide greater clarity in respect to your professional business. Professional business description Upload any brochures or promotional material Upload or drag files here Optional – Attaching documents can help us assess your business more accurately. Previous Next Section 3 – General information 1. Does the Company have operations outside of Australia? YesNo If YES, does the Company have operations in the USA/Canada? YesNo If YES, please provide further details 2. Have any Claims been made against the Company for professional negligence, error or omission in the last 5 years? YesNo If YES, please provide details of the claim(s), amounts and any payments 3. Is the Proposer aware, after enquiry, of any circumstances or incident which may give rise to a Claim? YesNo If YES, please provide further details 4. Do you have any Professional Indemnity Insurance cover currently in place? YesNo If YES, please state: Name of Insurer Limit of Indemnity Deductible Expiry Date of the Policy Retroactive Date Previous Next Section 4 – Income details Please provide a breakdown of your gross fees/income by Professional Business for the last financial year and the current financial year, either by whole amounts in AUD ($) or by percentage. (If your profession is in the property industry or similar, please complete any relevant Addendum Questionnaire.) Professional Business income breakdown Professional Business Percentage Breakdown % Last Financial Year’s Gross Fees $ Current Financial Year’s Gross Fees $ Percentages should total 100%. Amounts can be left blank if providing percentages only (and vice-versa). In respect of gross fees/income for the last financial year, please provide a breakdown by State NSW % ACT % QLD % VIC % TAS % SA % WA % NT % O/S % Total 100% O/S = outside Australia. Total should equal 100%. Please provide any additional detail about how your income is generated. You may attach brochures or promotional material that clarifies your professional business. Additional income detail Upload supporting documents Upload or drag files here Please provide details of the 5 largest contracts or projects undertaken by the Insured Project Description / Contract Fees / Income $ Project Value $ Date Completed (dd/mm/yy) If your browser shows a yyyy-mm-dd date picker, that’s OK—the format will be normalised in the submission. Previous Next Section 5 – Employee information Total number of employees Number of Principals, Partners, Directors Number of qualified employees Please provide details for each of the Insured’s Principals, Partners or Directors Name Age Qualifications Date Qualified No. Years of this Practice If Previous Business Cover is required, please complete: Name of Principal/Director/Partner requiring this cover Date left previous business Any claims/circumstances against previous business? Was the Professional Business conducted at the previous firm as per details in Section 2? YesNo If NO, please provide further details of your Professional Business while working at the previous firm Previous Next Section 6 – Limit of indemnity required Please state the required limit $250,000$500,000$750,000$1,000,000$2,000,000$4,000,000$5,000,000$10,000,000Other (specify below) Other Shown only if “Other (specify below)” is selected. Declaration Signing this Proposal Form does not bind the proposer or the Insurer to complete this insurance. The undersigned declares that the statements and particulars in this Proposal Form are true and that no material facts have been misstated or suppressed after enquiry. The undersigned agrees that should any of the information given by us alter between the date of this proposal and the inception date of the insurance to which this proposal relates, the undersigned will give immediate notice thereof. The undersigned agrees that the Underwriters may use and disclose our personal information in accordance with the “Privacy Collection Statement” above. The undersigned acknowledges that they have read this Proposal Form, including all Important Notices, as well as the policy wording and associated endorsements and are satisfied with the coverage provided, including the limitations and restrictions on coverage. 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. To be signed by the Insured for whom this insurance is intended for Full name Position Signature Date Previous Next
