Professional Indemnity Insurance Proposal

 

To receive a confirmed quote, please complete the form below. Depending on the details of your profession, we will endeavour to provide you with a confirmed quote on the same business day or the next business day if received after hours.

If you prefer to talk to a broker first, please call Liability Brokers between 8.15am and 5.15pm E.S.T. business days and receive an indicative quote over the phone.

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

Brokers Name:

Client Details

Insured Name

Trading Name

ABN No.(if known)

Full Address

Email Address

Website Address

Phone No. *

Do you require cover for any subsidiary, joint venture or associated company?
Yes    No

 

Professional Duties

What is your occupation (eg.management consultant):

The Insurer needs to understand exactly what you do. Detail in easy to understand English what your job entails and to what industries you perform your work.

Are you involved in corporate consulting to large Public Companies?
Yes    No

 

Qualifications

Do you hold the necessary qualifications required to perform all the tasks for this profession?
Yes    No

 

Previous Insurance

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

 

Quote Required

Please nominate the amount of covers you require:

Professional Indemnity:

Public Liability:

 

Underwriting questions

No. of people in the business

Gross Revenue - last year   If Nil, put in "0"

  Australia

  USA / Canada

  Overseas

Estimated for next year   If Nil, put in "0"

  Australia

  USA / Canada

  Overseas

 

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

 

Manual Risk Exposure

Does your occupation involve manual risk exposure?
ie. does your occupation involve:

  • Manual labour or manual tasks performed by yourself (apart from measuring)
  • The supervision of manual labour or manual tasks performed by other parties
  • The responsibility of manual labour or manual tasks performed by other parties
  • The training of others on how to perform manual tasks
Yes    No

 

Insured's History...

Have any claims been made against You or Your business or any prior business or has any fact or circumstance been notified to insurers that has the potential to give rise to such a claim?
Yes    No

Is anyone in the business aware of any CIRCUMSTANCES which may give rise to a claim against this business?
Yes    No

Have you (or any person receiving cover under this policy) ever:

  • Had insurance cancelled or declined by an Insurer?
  • Had a renewal refused or claim rejected by an Insurer?
  • Had any special conditions imposed?
  • Suffered a loss whether insured or not (last 5 years only)?
  • Been involved in a company that has been declared bankrupt or insolvent?
  • Been liable for any civil offence or pecuniary penalty?
  • Been charged or convicted for any criminal offence?
  • Been charged or convicted for fraud, theft or dishonesty?
Yes    No


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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 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:

 


 

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 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
This declaration is for a claims made and notified Policy of insurance. This means that the Policy covers you for claims made against you and notified to the insurer during the period of cover. This Policy does not provide cover in relation to:

  • claims made after the expiry of the period of cover even though the event giving rise to the claim may have occurred during the period of cover;
  • 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 cover;
  • facts or circumstances of which you first became aware prior to the period of cover, 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 cover 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.