Professional Indemnity Questionaire

Professional Indemnity Quote

Please take the time to complete our online quote form.

Please list the names of all entities to be insured (including ABN where possible):

Please advise the limit of indemnity required for Professional Indemnity insurance? (you can select multiple options if you would like a quote for various options)

Please advise the limit of liability required for Public Liability insurance? (you can select multiple options if you would like a quote for various options)

Not Required $5million $10million $20million

What are the professional services you provide (if you conduct multiple services, please list & advise a % split of your activities based on turnover)?

In relation to your business activities, please advise which of following circumstances applies to you (you can select multiple options):

You are intending to change the professional services described in the previous question
You have in the past been engaged in another professional service or activity other than those you have described in the previous question
You have been involved in mergers, acquisitions or joint ventures in the last five years
Cover is required in respect of the conduct of a former subsidiary or previous business of any principal, director or partner
You conduct business or derive income from activities outside Australia
None of the above apply to me

If yes, please provide as much information as possible:

When was your business established?

(Year)

Please advise your website/s for your business (if applicable)?

Please advise the total number of staff you have?

Directors, partners, principals
Qualified/Technical Staff
Consultants
Administration/Other Staff

Do you subcontract any of your activities (if yes, please answer the three following questions)?

What activities are subcontracted?

Please what % of work is subcontracted?

How much do you pay to sub-contractors annually ($)

Please answer the following in relation to your Duty of Disclosure. In the past 10 years have you or any Insured person / business / corporation / director:

1. Had any insurer decline any proposal from inception or decline any claim, cancelled or refused to renew a policy or imposed special conditions?
2. Ever been declared bankrupt or involved in any form of insolvency administration and not been discharged for at least one year?
3. Been convicted or have charges pending, for any criminal offence, including arson, or involving dishonesty of any kind?

If you answered yes to any of the above matters that need to be disclosed to the insurer, please provide the details below including dates:

Please answer the following in relation to your claims history. In the past 10 years:

1. Has any claim been made against you or any principal, partner or director(either as a principal, partner or director of the Insured or of any previous business),consultant or employee in respect of the risks to which this proposal relates?
2. Have you or any principal, partner, director, consultant or employee incurred any other loss or expense which might be within the terms of the Professional Indemnity cover?
3. After enquiry, are you aware of any circumstances which might give rise to a claim against the Insured or his/her predecessors in business or any of the present or former partners, principals, directors, consultants or employees?

If you answered yes to any of the above claims matters that need to be disclosed to the insurer, please provide the details below including dates:

Are you aware of any exceptional circumstances, not covered above, that would influence the underwriter's decision to accept the risk of insurance, or alter the terms? If so, please advise below:

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Disclaimer

Financial Services Guide

Contact

Phone : 1300 554 165

Email: info@coveriteinsurance.com.au

Post: PO Box 403, FORTITUDE VALLEY QLD 4006

Coverite Insurance is a Corporate Authorised Representative of Insurance Advisernet Pty Ltd AFSL No. 240549 Corporate Authorised Representative No. 404246
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