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Consultants PI & PL - Renewal Form

   

Please fill out the following form. Once you have completed the form, click the Submit button to send your information. Your insurance renewal will be handled promptly.

Client Code:   (refer email)
Insured Name:
Email Address:
No.of employees
   (including directors)

Professional duties...
Has there been any change in your profession (as disclosed in your
your previous Proposal), or are there any major changes contemplated
over the next 12 months? 		    Yes    No

If "YES", please give a brief description of the changed activities:

   

Fee income...

Gross income/fees for the past 12 months & an estimate of fees for next year.

NOTE: If no fees, then put "0"

2010-2011 2011-2012
Australia
USA or Canada   
Elsewhere
Total
If you perform work outside Australia, or work for clients located overseas,
please provide an approximate percentage breakdown by country.

   

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

   

Have you been subject to disciplinary proceedings for
professional misconduct? 		Yes    No
If "YES", please give details:
Does your business involve manual risk exposure? Yes    No
ie. does your occupation involve:
1. Manual labour performed by yourself
2. The supervision of manual labour performed by other parties or
3. The responsibility of manual labour performed by other parties.
If "YES", please give details:
Do any circumstances exist that might give rise to a claim
against any Insured that have not been notified to QBE? 		Yes    No
If "YES", please give details:
Have any claims been made against the Insured that might
give rise to a claim, that have not been notified to QBE?		 Yes    No
If "YES", please give details:

  

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:     Date:







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