Professional Indemnity Insurance Proposal Form for Architects

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1 JMD Ross Insurance Brokers Pty Ltd ABN Level 6, 1 Chandos Street PO Box 411 St Leonards NSW 2065 St Leonards NSW 1590 Tel: Fax: JMD Ross Insurance Brokers Pty Ltd operates as a strategic partner in Australia Griffiths & Armour Professional Risks Ltd (UK) Professional Indemnity Insurance Proposal Form for Architects IMPORTANT - ALL QUESTIONS MUST BE ANSWERED. PLEASE ATTACH SEPARATE PAGES IF REQUIRED. 1. (a) Full title of practice/firm and subsidiary practice(s)/firm(s) and former practice(s)/firm(s) for which cover is required (b) Please provide ABN for each company 2. (a) Date current practice(s)/firm(s) started (b) Date of start and finish of former practice(s)/firm(s) (c) Reason for cessation of former practice(s)/firm(s) 3. Profession (Please attach brochure(s), if available) 4. (a) Principal address (b) Postal address (if different above) (c) All other locations (city only) (d) Website address (e) Contact number (It is undersod and agreed that material on the practice/firm s website is not deemed form part of this proposal, apart from any information attached the proposal form) 5. Details of direcrs* Name Period of time as a direcr Qualifications Date qualified * If you are a sole practitioner and unqualified, please provide a curriculum vitae outlining all relevant experience Professional Indemnity Insurance Proposal Form for Architects 1

2 6. Is cover required for any direcr for their liability arising from any previous business? YES NO If YES, please advise Name Title of previous business Date direcr left business Limit of indemnity required if less than stated in Q19 7. Total number of staff (including direcrs) (a) Professionally qualified (b) Technicians/assistants (c) All others 8. (a) State gross fees received in the past five financial years and estimated fees for the forthcoming year / / / / / Forthcoming year Australia Overseas (ex USA/Canada) USA/Canada Total (a) When does your financial year end? (c) Please provide a geographical breakdown of income for last financial year NSW VIC QLD SA WA TAS NT ACT Overseas Total % % % % % % % % % 100% 9. Please give details as a percentage of the firm s/practice s tal gross fees in the last complete financial year or estimate (if this is a new start up) for the following activities. (Please ensure discipline and operational facrs both equal 100%) (a) Discipline Facrs Australia % Elsewhere % Architecture Structural refurbishment (architectural) Non-structural refurbishment Interior design Landscape Feasibility studies Town planning Project co-ordination/project management Expert witness Master planning Graphic design Other (please specify) Total 100% Professional Indemnity Insurance Proposal Form for Architects 2

3 (b) Operational Facrs Australia % Elsewhere % Public secr housing Private secr housing High rise (over three sreys) Bulk handling/mechanical plant Schools/universities Industrial Marine/railway Hospitals/municipal Office/commercial/public Swimming pools - domestic Swimming pools - commercial Stadia/sports arenas/surfaces Hotels and leisure centres Retail/supermarkets Multiple housing Housing associations Clean air environments Other (please specify) Note For work in the USA, please provide a separate split of tals/estimates. Total 100% 10. Does the practice or any direcr act on behalf of or undertake work for any firm, YES NO company or organisation in which the practice or any direcr has a financial interest (other than superannuation investments)? If YES, please give details 11. Does the practice or any direcr have any association with or financial YES NO interest in any other practice, company or organisation (other than as shareholders/sckholders in publicly quoted companies)? If YES, please give details of the nature of the association and the name and business of the other practice, company or organisation Professional Indemnity Insurance Proposal Form for Architects 3

4 12. (a) State the five largest contracts where construction has started during the past five years Start date and approx completion date Description of contract and location (e.g., hotel, facry etc) Total project value Total professional fees Professional services provided (b) As applicable, state the proportion of work where the practice both designs and undertakes limited or full superintendence % 13. Is the practice or any direcr a member of a consortium or group practice YES NO or engaged with any other practice or person in a single project partnership? If YES, please give the names of the direcrs and their involvement in the consortium/group practice 14. Does the practice/firm enter in (or has entered in in any of the last six years) YES NO joint venture partnerships or does it intend do so within the next 12 months? If YES, a supplementary questionnaire will be required. 15. (a) Has the practice/firm engaged sub-consultants, or undertaken any contracts YES NO where it has become contractually responsible for the services of any sub-consultant in the last six years or does it plan do so in the next 12 months? (b) Is there a clearly defined procedure in place ensure any sub-consultant is: (i) Engaged on contractual terms that are at least as onerous as YES NO the contractual terms under which the practice/firm has been engaged? (ii) Professionally competent undertake the work in question? YES NO (iii) Adequately insured cover any liability likely arise for YES NO the work in question? If NO any of 15(b)(i) (iii) above, please answer the following question: (iv) What procedures are in place manage and control the appointment of sub-consultants by the practice/firm? Professional Indemnity Insurance Proposal Form for Architects 4

5 16. In the past 10 years, have any claims (including circumstances which might give rise a claim) for professional negligence, error or omission (successful or otherwise) been made against the practice or its present and/or past direcrs? If YES, please give full details, including amounts involved. YES NO 17. Other than under Q16, are any direcrs aware of any circumstances that may give rise a claim against this practice or its predecessors in business or any present or former direcrs? If YES, please give details YES NO 18. Is the practice/firm presently insured? YES NO Name of broker/insurer Indemnity limit/ aggregate limit Amount of excess Premium (excluding taxes and charges) Renewal date How long continuously insured? $ /$ $ $ 19. Indemnity limit required $ If alternatives are be considered, please indicate $ 20. Has any application for this type of insurance made by you or your predecessors in business ever: (a) been declined or subject increased premium? YES NO (b) been subject special conditions or been terminated by an insurer? YES NO If the answer any of the above is YES, please explain why DECLARATION - VERY IMPORTANT I/We have read over all the statements and particulars given in this proposal (including any answers written for me/us by any other person) and I/we declare that, the best of my/our knowledge and belief, they are correct and no material fact has been misrepresented or misstated. I/We agree that, in the event of the risk being accepted, the statements and particulars contained in the proposal and the terms and conditions of the policy be issued shall be the basis of the contract and I/we undertake pay the premium when called upon do so. Signature of Direcr Date Professional Indemnity Insurance Proposal Form for Architects 5

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