Professional Indemnity Proposal For Miscellaneous Occupations

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Rudolf Paul
8 years ago
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P 1800 096 829 F 1800 096 680 A.F.S Licence 244370 A.C.

1 P F A.F.S Licence A.C.N Professional Indemnity Proposal For Miscellaneous Occupations IMPORTANT NOTICE This Proposal Form must be typed, or completed in ink and signed and dated by the Proposer: Please answer every question fully, and state NIL or NONE as applicable. Incomplete answers may not be accepted and can delay quotation. Should there be insufficient room in the Proposal Form for full details, please use the additional information section at the end of the Proposal. Please also attach any supporting information which you feel may assist us in understanding your professional business practice It is the duty of the Proposer to disclose all material facts to Underwriters. Where this is omitted, the Underwriters may avoid their obligation under the Policy. For the purpose of the Proposal and for all purposes relating to any policy issued pursuant to this Proposal, a material fact shall be deemed to be one that would be likely to influence an Underwriter s judgment and acceptance of your proposal. Upon acceptance of the Underwriters terms and conditions and payment of the premium, all information provided by the Proposer together with the guidance notes will be deemed to be incorporated in the contract between Underwriters and the Insured. Your Insurance includes a provision that has the affect of excluding or limiting OUR liability under the Insurance in respect of a loss by reason that you are, or have been, a party to an agreement that excludes or limits YOUR rights to recover damages from a party in respect of the loss. Copies of the Proposal Forms should be retained for your records. High Street Underwriting Agency - Professional Indemnity Proposal HSUA

every question fully, and state NIL or NONE as applicable. Incomplete answers may not be accepted and can delay quotation.

2 YOUR DETAILS 1. Name Commencement date of Insured (Full names of all entities requiring cover including trading names): business 2. Contact Details Business Address: Suburb: State: Postcode: Phone: Fax: Mobile: Website: PERIOD AND LIMITS OF INSURANCE 1. Period of Insurance (a) Insurance cover is needed from: to: _ 2. Insurance Limits (a) For what limits of indemnity do you require quotation: $1,000,000 $2,000,000 $5,000,000 $ Other (please specify) (b) Do you require any of the following extensions? (i) Libel & Slander. (ii) Dishonesty of Employees. (iii) Loss of Documents. (iv) Unintentional Breach of Copyright. (v) Unintentional Breach of Confidentiality. BUSINESS PARTICULARS 1. Business Description Full description of your Business: High Street Underwriting Agency - Professional Indemnity Proposal HSUA

Insurance Limits (a) For what limits of indemnity do you require quotation: $1,000,000 $2,000,000 $5,000,000 $ Other (please specify) (b) Do you require any of the following extensions?

3 2. Fees Please give the total annual gross fees for advice given in each of the last two Financial Years and an estimate for the current 12 months: Year Australia Overseas Estimated Current Financial Year $ $ Last Financial Year $ $ Previous Year $ $ Please state the date of your Financial Year End : 3. Qualifications Please list all Partners/Directors/Principals of your Firm: Please give total number of: Partners/Directors/Principals: _ Qualified staff: Other Staff: 4. Sub-Contractors (a) Do you use sub-contractors? Date Obtained - If '', please provide further details below: (b) Estimated Annual Payments $ (c) Nature of work performed: (d) Do all sub-contractors carry their own professional indemnity insurance? (e) Names in Full Qualifications - If '', to what limit of Indemnity $ Do you always check the Insurance s of sub contractors? How long a Partner/ Director/Principal 5. Other Information (a) Does the firm enter into any written agreements or letter of appointment? If '', please enclose copies. (b) Does the firm issue any literature, etc. describing the services If '', please enclose examples High Street Underwriting Agency - Professional Indemnity Proposal HSUA

Qualifications Please list all Partners/Directors/Principals of your Firm: Please give total number of: Partners/Directors/Principals: _ Qualified staff: Other Staff: 4.

4 (c) Please provide details of the five largest Contracts undertaken in the past 5 years: Title of Contract Fee (d) Please provide details of the two largest Contracts expected to be undertaken in the forthcoming year: Title of Contract Fee (e) Are you involved in any process of manufacture, construction, alteration, repair, installation or sale or supply of materials and equipment, other than in a pure consultancy capacity as previously described? (f) If '', Please give full details: (g) (h) Has the Firm or any of the Partners/Directors/Principal ever been a member of consortium or a joint venture? If '', Please give full details: (i) (j) Do you require this insurance to provide for legal actions bought? (a) Only in the Courts of Australia. (b) In Courts anywhere in the world other than the USA & Canada. Does the Firm or any Partners/Directors/Principals have an association with or a financial interest in any other firm or organisation? If '', Please give full details: 6. Business Operations Outside Australia (a) Do you operate outside Australia? - If '', please provide further details below: (b) Location Operations Annual Gross Fees High Street Underwriting Agency - Professional Indemnity Proposal HSUA

a pure consultancy capacity as previously described?

5 7. USA and Canada (a) Have you given Power of Attorney to any person or corporation in the USA or Canada? (b) Do you have any assets/company located in the USA or Canada? (c) Do you have any employees or other representatives in the USA or Canada? (d) Please supply copies of all contracts in relation to the USA or Canada. 8. Claims / Insurance History (a) Do you currently have insurance? If '', Please complete the following: Please advise the name of the holding Underwriter: _ Limit of Indemnity: $ Excess applicable: $ Expiry Date: Has any claim for professional negligence, error or omission ever been (b) made against the Firm and or Partners/Directors/Principals or employees and or their predecessors in the Firm whether insured or not? - If '', please provide further details below: Date Particulars Cost Name of Insurer (if any) (c) Are any of the Partners/Directors/Principals or employees AFTER ENQUIRY aware of any circumstances which are likely to give rise to a claim against the Firm or its predecessors in business or any of its present or former Partners/Directors/Principals or employees? - If '', please provide further details below: Date Particulars Cost Name of Insurer (if any) (d) Has any insurer ever declined indemnity for any claim made by you? - If '', please provide further details below: (e) Has any insurer declined, refused to renew, cancelled or imposed special conditions to any policy of insurance held by you? - If '', please provide further details below: High Street Underwriting Agency - Professional Indemnity Proposal HSUA

Claims / Insurance History (a) Do you currently have insurance?

6 DECLARATION I/We declare and warrant that after enquiry all statements and particulars contained in this proposal and addenda are true and that no information whatever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this proposal and should the above particulars alter in any way I/We will advise the Underwriters as soon as practicable. I/We understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of the proposal may result in the Underwriters refusing to provide indemnity or voiding the policy in every respect. I/We hereby agree and accept that this Declaration shall be the basis of the contract between both parties if entered into. For and on behalf of (Name of Company):_ Signature : Dated: (print and sign in pen) Name of Signatory: Position: Where the answers are not in my/our handwriting they have been checked jointly and/or severally by me/us and are certified as correct. Signature : Dated: (print and sign in pen) Signing of this Proposal Form does not bind the Proposer or Underwriters to complete a contract of Insurance. Form Return Details Please return the completed form to your Insurance Broker For Brokers Only, please return this form to info@hsua.com.au. P F E info@hsua.com.au W High Street Underwriting Agency - Professional Indemnity Proposal HSUA

I/We understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of the proposal may result in the Underwriters refusing to provide

7 ANY ADDITIONAL INFORMATION YOU WISH TO PROVIDE High Street Underwriting Agency - Professional Indemnity Proposal HSUA

Public & Products Liability Proposal

P 1800 096 829 F 1800 096 680 A.F.S Licence 244370 A.C.N 096 939 169 Public & Products Liability Proposal IMPORTANT NOTICE This Proposal Form must be typed, or completed in ink and signed and dated by