Professional Indemnity...
Recruitment & Employment Agencies

Please complete this form below

Do you have a renewal due and want an alternative quote. The easiest way to get a comparison quote is to send us a copy of your renewal proposal.

If you need any help or advice, please call    1300 881 779

 

 
If you have already spoken to someone in our office, please note their name here so that this form can be processed by them as they will know something about you already.

Brokers Name:

Insured Name:
Trading Name:

ABN No.(if applicable):
Address:
Email Address:

Website Address (if applicable):

Telephone No:

Start date of business:

Underwriting Questions

Do you provide Temporary Workers in the following industries?
  • Aerospace, Aircraft, & Radar Installations
  • Chemical Industries
  • Electricity or Nuclear Installations
  • Medical Industry
  • Marine Industry
  • Military Installations
  • Mining Industry
  • Oil /Petro-Chemical Industries
  • Off Shore Rigs
  • Scientific/Research Fields
Yes    No

Do you provide Temporary Workers who become involved in the use of oxy-acetylyne welding or flame cutting plant, blowlamps or torches
Yes    No

Do you hold the necessary qualifications to perform all the duties of your profession?
Yes    No

Underwriting Questions

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

Permanent Staff

Please provide breakdown of fee income from the placement of permanent staff?

Office / Clerical staff $

Managerial / Supervisory $

Professionals eg.Accountants $

Nursing & Care Workers $

Hospitality $

IT Industry $

Tradesmen $

Manual Labour $

Other $

Temporary Staff

Please indicate the gross wages paid to Temporary Staff sent to work at clients premises:

Office / Clerical staff $

Managerial / Supervisory $

Professionals eg.Accountants $

Nursing & Care Workers $

Hospitality $

IT Industry $

Tradesmen $

Call Centres $

Agriculture $

Welders $

Drivers / Warehousemen $

Manual Labour $

Other $

Contractors

Please indicate the payments made to Contractors you hire that are not classed as your employees (ie they have their own ABN):

Office / Clerical staff $

Managerial / Supervisory $

Professionals eg.Accountants $

Nursing & Care Workers $

Hospitality $

IT Industry $

Tradesmen $

Call Centres $

Agriculture $

Welders $

Drivers / Warehousemen $

Manual Labour $

Other $

Quote Required

Please nominate the amount of covers you require:

Professional Indemnity  .    

 Public Liability
$500,000

Not required

$1,000,000

$5,000,000

$2,000,000

$10,000,000

$5,000,000

$20,000,000

$10,000,000

Please state the percentage of Your activities (based on income) applicable to each State
ACT NSW NT QLD
%    %    %    %   
SA TAS VIC WA O/Seas
%    %    %    %    %

Contractors

Do you employ contractors, sub-contractors?
Yes    No

Insured's History

The term "You" has the following meaning in the questions below: principals, partners, directors or staff members, or any of the Intended Insureds predecessors, or any prior practice of any of its present or former partners, principals or directors

Have "You" ever been subject to disciplinary proceedings or actions for misconduct in a professional respect?
Yes    No

Have "You" ever been subject to any claims for civil liability or breach of professional duty in the last ten years?
Yes    No

Have "You" notified circumstances to insurers that may give rise to such a claim?
Yes    No

Are "You", after reasonable enquiry of all staff and managers, aware of any other facts or circumstances which may give rise to a professional indemnity insurance claim?
Yes    No


Security: Type the above number:



Declaration...

By submitting this Declaration, I/we declare and agree that:
  • I/we have the consent of all other persons covered by this policy to make this Declaration,
  • the contents of this Declaration are true and complete,
  • I/we have read the information concerning the duty of disclosure (immediately below this declaration);
  • I/we have answered every question fully and frankly, have been truthful and accurate in completing this application and have not withheld any information likely to affect the acceptance of this insurance;
  • I/we realise that if I/we have not complied with the duty of disclosure, any claims may not be met
  • if anything happens during the Period of Cover which alters any of the information provided, I/we will promptly inform the insurer;
  • I/we confirm that I/we have read and understood that this policy operates on a claims made and notified' basis; (refer - Claims Made Policy below)
Name of person making this declaration:

 


 

Duty of Disclosure What you must tell us
Under the Insurance Contracts Act 1984 (the Act), you have a Duty of Disclosure. You are required before you enter into, renew, vary, extend or reinstate your Policy, to tell us everything you know and that a reasonable person in the circumstances could be expected to know, is a matter that is relevant to our decision whether to insure you, and anyone else to be insured under the Policy, and if so, on what terms.
  • You do not have to tell us about any matter
  • that diminishes the risk
  • that is of common knowledge
  • that we know or should know in the ordinary course of our business as an insurer, or
  • which we indicate we do not want to know.
  • If you do not tell us
If you do not comply with your Duty of Disclosure we may reduce or refuse to pay a claim or cancel your Policy. If your non-disclosure is fraudulent we may treat this Policy as never having worked.

Claims Made Policy
The Professional Indemnity section of this Policy operates on a 'Claims made and notified' basis. This means that the Policy covers you for Claims made against you and notified to us during the Period of Insurance.
This Policy does not provide cover in relation to:
  • acts, errors or omissions actually or allegedly committed prior to the retroactive date of the Policy (if a date is specified);
  • claims made after the expiry of the period of insurance even though the event giving rise to the Claim may have occurred during the period of insurance;
  • claims notified or arising out of facts or circumstances notified (or which ought reasonably to have been notified) under any previous Policy;
  • claims made, threatened or intimated against you prior to the commencement of the period of insurance;
  • facts or circumstances of which you first became aware prior to the period of insurance, and which you knew or ought reasonably to have known had the potential to give rise to a Claim under this Policy;
  • Claims arising out of circumstances noted on the proposal form for the current period of insurance or on any previous proposal form.
Where you give notice in writing to the insurer or any facts that might give rise to a claim against you as soon as reasonably practicable after you become aware of those facts but before the expire of the period of cover, you may have rights under Section 40(3) of the Insurance Contracts Act 1984 to be indemnified in respect of any claim subsequently made against you arising from those facts notwithstanding that the claim is made after the expiry of the period of cover. Any such rights arise under the legislation only. The terms of the Policy and the effect of the Policy is that you are not covered for claims made against you after the expiry of the period of cover.