Builtin Form

Your Information

Name*

Business Name

Are you registered for GST?

Yes
No

New Zealand Business Number (NZBN)

Best Contact Number*

Email*

Address*

Insurance Requirements

Are you currently insured?*

Yes
No

Current Insurer

Current Policy Expiry Date

Professional Indemnity Cover Required*

$1,500,000
$2,000,000
$5,000,000
Other

If other, please advise limit*

Do you also require Public Liability Cover?*

Yes, please include $10,000,000 cover
Yes, please include $20,000,000 cover
No thanks

About Your Business

Total Fees Received - Last 12 Months Actual*

Gross Fees (Ex GST) should include all income received for your professional services including fees that are on-paid to Sub-Contractors.

Total Fees Received - Next 12 Months Estimated*

Gross Fees (Ex GST) should include all income received for your professional services including fees that are on-paid to Sub-Contractors.

Do you recieve any fees outside of New Zealand?

Yes
No

If yes, please provide further information*

Type of Services Provided

Please tick all services below that apply to you*

Air Tightness Testing and Measurement
Passive House Consulting
Building Diagnostics
Other Energy Efficiency Work
Other Services not listed above

Note this policy will only provide cover for the activities declared and agreed on the policy schedule. Please list ALL professional services that your business offers.

Please tick all Energy Effeciency services below that apply to you*

House Energy Rating Assessments (HERS)
Thermal Performance Assessments
Commercial Energy Rating Assessments
Home Sustainability Assessments
Energy Efficiency Assessments
Professional Advice Relating to the above services
Quality Assurance Audits
BASIX Certification
Other Services not listed above

Note that this policy will only provide cover for the activities listed above. This policy is not suitable if you also require cover for services including Building Design. We can cover this on a separate policy.

If other, please advise further details*

Type of Buildings Rated

Please state the approximate percentage of your Gross Professional Fee income derived from or relating to the following types of buildings

Domestic Residential Buildings (Includes Townhouses & Units)

Multi-Residential Apartments

Commercial Buildings

Municipal & Government Buildings

Other Buildings

If other, please advise further details*

Claims Experience

The term YOU in the questions below relates to your Firm, Company or you as a Sole Practitioner including present or former Partners, Directors, Principals, Consultants, or Employees.

During the past ten years has any claim been made, or has liability for an error or breach of duty been alleged against YOU; or have any circumstances been notified to insurers which may result in a claim?*

Yes, I have something to declare
No, I have nothing to declare

Are YOU, AFTER FULL INQUIRY, aware of any circumstances which may give rise to a claim?*

Yes, I have something to declare
No, I have nothing to declare

If Yes, please provide further details*

Have YOU ever been subject to disciplinary proceedings for professional misconduct, any enquiry or audit?*

Yes, I have something to declare
No, I have nothing to declare

Has any insurer ever declined to offer Insurance of any type or imposed special terms for YOU?*

Yes, I have something to declare
No, I have nothing to declare

If Yes, please provide further details*

Has any insurer ever cancelled or voided any Insurance held by YOU?*

Yes, I have something to declare
No, I have nothing to declare

Is any partner/director/principal/employee connected or associated (financially or otherwise) with any other Practice or Business?*

Yes, I have something to declare
No, I have nothing to declare

If Yes, please provide further details*

Have YOU been charged with or convicted of any criminal offence?*

Yes, I have something to declare
No, I have nothing to declare

Have YOU been declared bankrupt, insolvent, had a liquidator appointed or been a defendant in any civil court case?*

Yes, I have something to declare
No, I have nothing to declare

If Yes, please provide further details*

Other Insurances

Do you require a quote or additional information on any other insurances?

Office / Contents Insurance
Management Liability Insurance
Cyber / Privacy Protection Insurance
Motor Vehicle Insurance
Income Protection / Life Insurance
Construction / Contract Works Insurance
Tools / Mobile Equipment Insurance
Home Insurance
Other Insurance

If other, please provide further information*

Additional Information

Is there any other information that you need to provide to the insurer?*

YES there is
NO there is not

If yes, please provide further information*

Important Information

Please take a moment to read these important documents prior to submitting your form.

Declaration

I/WE declare that we have read the important notices attached above and I/WE understand those notices.
I/WE undertake to inform insurers of any material alteration to these facts whether occurring before or after completion of the Contract of Insurance.
I/WE hereby acknowledge that the insurance cover may be provided in whole or in part by overseas insurers.

Please tick all to confirm that you have read the following documents:*

Privacy Policy
Terms of Business
Disclosure Statement

Signature

This electronic signature will be treated the same as if signed personally.

Builtin Energy & Air Tightness Quote Request Form

Your Information

Insurance Requirements

About Your Business

Type of Services Provided

Type of Buildings Rated

Claims Experience

Other Insurances

Additional Information

Important Information

Declaration

Signature

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