Brokers Name:

Client Details

Insured Name

Trading Name

ABN No.(if known)

Full Address

Email Address

Phone No. *

Professional Duties

Please provide a breakdown of Your business activities.

Income by Type of Service

%  Energy Assessing / Energy Rating

%  Carbon Accounting

%  Other Assessing:

If Other, please provide details:

Area of Industry

Please provide a breakdown of the areas of Your business activities.

Income by Area of Service

%  Residential dwellings

%  Schools, hospitals, municipal buildings & recreational centres

%  Small commercial properties valued at $1,000,000 or less

%  Medium commercial properties valued from $1,000,000 to $5,000,000

%  Large commercial properties valued in excess of $5,000,000

%  Other

If Other, please give details

Note: If your total fee income is from Residential Dwellings only ie. Residential dwellings 100%, we will rate you as Energy Assessors - Residential Only. (This will entitle you to a lower premium).

Do you agree to be rated as Energy Assessors - Residential Only?
Yes    No

Underwriting questions

No. of directors /partners:  

No. of qualified assessors:  

What is your annual business turnover?
$ 

Please state the percentage of Your activities (based on income) for each State

Manual Risk Exposure

If you are after Public Liability cover as well, we need this question to be answered, otherwise proceed to the next question.

Does your business involve any of the following?

• Manual labour or manual tasks performed by yourself (apart from measuring)
  
• The supervision of manual labour or manual tasks performed by other parties or
  
• The responsibility of manual labour or manual tasks performed by other parties.
  
• The training of others on how to perform manual tasks

If you answered Yes, what duties do they perform?

Contractors

Do you employ contractors, sub-contractors?
Yes    No

If you answered Yes, what duties do they perform?

Do You require cover for sub-contractors?
Yes    No

If "NO", do You insist they carry their own insurance?
Yes    No

Quote Required

Please nominate the amount of covers you require:

Professional Indemnity

$1,000,000

$2,000,000

$5,000,000

$10,000,000

Public Liability

Not required

$5,000,000

$10,000,000

$20,000,000

Insured's History

Have you been previous insured for Professional Indemnity?
Yes    No

If you answered "Yes", please provide the following details:

Insurers Name

Limit of Indemnity
$

Expiry date

Have any claims ever been made against You, your predecessors in business or of the present or past Partners or directors?
Yes    No

Are you aware, after enquiry, of any CIRCUMSTANCES which may result in any claims against you, your predecessors in business or any of the present or former Partners/Principals?
Yes    No

Declaration

By submitting this Declaration, the Applicant acknowledges:

• they are authorised by each of the other Applicants to make this Declaration,
• the contents of the Declaration are true and complete,
• they are under a continuing obligation to immediately inform the insurer of any change in the particulars or statements contained in this Declaration or in the accompanying documents up until the contract is entered into,
• they authorise the insurer to give or obtain from other insurers or insurance reference bureaus or credit reporting agencies, any information about this insurance or any other insurance held by the Applicant/s.

Name of person making this declaration: