Engineers, Architects, Surveyors and Relation Professions

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1 Application Form Professional Indemnity Insurance Send quotation requests to: Phone: Engineers, Architects, Surveyors and Relation Professions IMPORTANT NOTICES Please read these Important tices before applying for this insurance. The Cover Professional Indemnity insurance is issued on a claims made basis. This means that the policy covers you for claims made against you and notified to the insurer during the period of insurance provided that you were not aware at any time prior to the start of the inception date of the cover, of circumstances that would have put a reasonable person in your position on notice that a claim may be made against you. Usually no new claim notification can be made after the period of insurance has ended even though the event giving rise to the claim may have occurred during the period of insurance. tification requirements are subject of Section 40 of the Insurance Contract Act 1984 Your policy will not insure you for any claims arising out of circumstances you were aware of at any time prior to the inception of the period of insurance. Information This application must be fully completed and you must report full details of all circumstances which have become known to you or that a claim arising from an event may be made against you. See your Duty of Disclosure below. If there is insufficient space on the application please use a separate signed and dated headed sheet of paper. Where available, brochures, standard contract conditions, agreements, letters of appointment should be provided. Duty of Disclosure 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 don t need to tell us about any matter: that reduces the risk, is of common knowledge, that we already know, or ought to know in the ordinary course of our business as an insurer, or we indicate we do not want to know. If you do not tell us 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 also have the option of avoiding the Policy from its beginning. Occurrence or Event tification During the period of insurance, if you become aware of any occurrence or event that may give rise to a claim and you during that period of insurance you have given written notice to the insurer of such

2 occurrence or event, any claim made subsequent to that notification shall be deemed to be a claim made during the period of insurance. Right of Recovery Where another person or entity would be liable to compensate you for any loss or damage covered by this insurance but you have agreed with that person or entity at any time that you would not seek to recover that loss or damage, this insurance policy will not provide cover for such loss or damage. Business Alteration You must notify us within 7 days of any material alteration to the business that is the subject of this insurance. Material alterations are (but not limited to); the nature of the business; acquisition or merger with another business; an insured person or entity being declared bankrupt or entering receivership; cancellation or suspension of statutory registration or professional association membership. Privacy Privacy legislation regulates the way private sector organisations can collect, use, keep secure and disclose personal information. has developed a privacy policy which explains what sort of personal information we hold about you and what we do with it. You can obtain a copy of the Breeze Underwriting Privacy information brochure by contacting us at or from our website 1. Broker Details Broker name: Address: Contact Name: Phone: A business unit of Professional Services Corporation Pty Ltd ABN AFS Licence Page 2 of 12

3 2. Client Details Name Trading Name Address City State Postcode Period of Insurance A.B.N. From: Phone To: Website Website 3. Description of Business 4. Current Insurance Details Current Insurer Current Broker 5. Year Business Established 6. Additional Business Entities (a) List all entities whether or not currently trading. Entity Year Established Year of Cessation (b) Do you require cover in respect of all past activities of the entities listed in (a)? A business unit of Professional Services Corporation Pty Ltd ABN AFS Licence Page 3 of 12

4 (c) List addresses of all other offices currently trading. Address Postcode 7. Business Details (a) Detail the percentage split of work in the following disciplines where you have undertaken or been responsible for design or technical services: Discipline % Structural Engineering Mechanical Engineering Electrical Engineering Civil Engineering Chemical Engineering Construction Management Project Management Town Planning Surveying - Land - Quantity - Building Architecture Environmental Engineering Mining Engineering Marine Engineering Drafting Interior Design Other (please specify) Total 100% A business unit of Professional Services Corporation Pty Ltd ABN AFS Licence Page 4 of 12

5 (c) Detail the approximate percentage of your work in the following areas: Area of Work % Individual Dwellings Low rise buildings up to 3 floors High rise buildings over 3 floors Institutional Buildings Feasibility Studies, investigations or reports (exc. environmental) Supervision of construction Bridges or Dams Mines, Oil Pipelines, Refineries Domestic Surveying (individual dwelling and boundary survey) Industrial and Commercial Surveys (projects up to $5 mio. In value) Industrial and Commercial Surveys (projects over $5 mio. In value) Marine Surveys Soil Testing and Foundation Investigations Mechanical Plant and Bulk Handling Equipment Environmental Reports Containment site clean-up Other (please specify) Total 100% (d) Are you or have you any parent, subsidiary or other related entity either engaged in, or have or had a controlling share of any entity engaged in: Activity Australia Overseas Actual construction, fabrication, erection or any form or works contracting Real estate development Manufacturing A business unit of Professional Services Corporation Pty Ltd ABN AFS Licence Page 5 of 12

6 (e) Do you engage in the manufacture or fabrication of any pre-engineered unit? If yes, please detail the type of work normally carried out, whether consisting of well established techniques or the nature of new and original thought developments, processes or designs employed: (f) Do you use independent specialist consultants? If yes, please supply details: (g) Do you require them to carry a minimum level of Professional Indemnity cover? If yes, please supply details: (h) Have any of the entities in this application ever been insured for professional indemnity. Insurer Name Expiry date Premium $ Excess $ Limit of Indemnity $ A business unit of Professional Services Corporation Pty Ltd ABN AFS Licence Page 6 of 12

7 (i) In respect of your Professional Indemnity, has any insurer declined an application, denied top pay a claim, refused renewal, imposed special conditions or cancelled a policy? (j) What is the amount of indemnity now required? $ 8. Staff and Partners (a) Details of all principals, partners and/or directors Name Age Relevant Qualifications # Date Qualified # Attach a CV where applicant has less been established less than 3 years or where the individual has no formal qualifications. (b) Numbers of employees in current business: Qualified Administrative Self Employed Consultants Other Total Full Time Part Time A business unit of Professional Services Corporation Pty Ltd ABN AFS Licence Page 7 of 12

8 (c) Is the applicant entity, principle, partner or director connected or associated, financially or otherwise, with any other entity? If yes, please provide details including income received: (d) During the past 10 years has the applicants name been changed or has any other business been purchased and/or has any merger or consolidation taken place? 9. Activities (a) Total fee income for the last financial year and estimate for current year and forthcoming year: Year Ending Australia $ Elsewhere (in Aus $) Total / / / / / / (b) Detail percentage breakdown of earnings specified in (a) by State or Territory: NSW VIC QLD SA NT WA ACT TAS Total 100% A business unit of Professional Services Corporation Pty Ltd ABN AFS Licence Page 8 of 12

9 (c) Detail your 5 largest contracts in the last 3 years where you have undertaken or been responsible for design or technical services Location and Description of Contract Services Performed Contract Value Date Commenced Completion Date (d) Is cover required for any activity undertaken in the last 6 years which has now ceased? (e) Are you aware of any change in activity or structure that may occur in the coming financial year? A business unit of Professional Services Corporation Pty Ltd ABN AFS Licence Page 9 of 12

10 (f) Is the entity involved in any process of manufacture, construction, alteration, repair, installation, sale or supply of products other than in a pure consultancy capacity? (g) Is the entity a member of any trade or professional body? (h) Do you use independent specialist consultants? If yes, do you require them to carry a minimum level of professional indemnity cover? A business unit of Professional Services Corporation Pty Ltd ABN AFS Licence Page 10 of 12

11 10. Claims Information (a) Detail any professional indemnity claims and/or circumstances made against the entities and/or predecessors of the entities and/or your current and/or retired partners, directors or principal, either individually or otherwise for any negligence,, errors, omissions, breach of professional duty or the like, whether successful or not: Date of Claim Claimant Name Details of Claim inc. any payments b) Are any of the partners, directors or principal aware of any pending claim and/or circumstances which may give rise to a professional indemnity claim against the applicant entity and/or predecessors of the entities and/or current and/or retired partners, directors or principals? Date of Circumstance Claimant Details A business unit of Professional Services Corporation Pty Ltd ABN AFS Licence Page 11 of 12

12 11. Signature and Declaration By completing and signing this application form, you declare that: 1. the disclosed information in this application is true an accurate in every respect and no information has been withheld which is likely to affect our decision about accepting this insurance; 2. If there is more than one insured and all have not signed this application, you have signed for and on their behalf; 3. you acknowledge we reserve the right to decline any application; 4. you acknowledge that if the applicant acquires, merges with or absorbs another practice or entity during the period of insurance, the insurer will require full details and may charge an additional premium; 5. you acknowledge that a signature on this application form does not provide insurance cover until the application is accepted in writing by the insurer. Signature (Principal, Partner or Director) Date Applicant s Title A business unit of Professional Services Corporation Pty Ltd ABN AFS Licence Page 12 of 12

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