Professional Indemnity Insurance Renewal Form by Liability Brokers

Home Sustainability Assessors - Renewal Form...

Please fill out the following form. Once completed, click the Submit button and a renewal quote will be produced.

This insurance is for Home Sustainability Assessors & Energy Raters only. If your business includes activities other than these, you need to complete one of our other forms which can cater for your multiple activities. Click here for access to other forms: Other Occupations or call us for advice.

Make sure you put in your correct email address as a copy of this submission will be emailed to that address.

If you need advice, please call Liability Brokers: 1300 881 779

Client Code:
Insured Name:
Trading Name:
Email Address:

Professional Duties...

Occupation

Does your business involve manual risk exposure?
Yes No

ie. does your occupation involve:

Manual labour peformed by yourself (apart from measuring)
The supervision of manual labour performed by other parties or
The responsibility of manual labour performed by other parties.

If "YES", please give details:

Assessors Names:
Only "Named Assessors" are covered under this policy

Please nominate those assessors to be insured below:

Insured's History...

Have any claims been made against YOU that might give rise to a claim
or are you aware of any CIRCUMSTANCES which may result in a claim
being made against you or anyone in your business? Yes No

If "YES", please give details:

Sum Insured ...

Professional Indemnity

Public Liability cover for $10,000,000 is automatically included

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 QBE 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 QBE Insurance (Australia) Limited 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:
Dated: