Professional Indemnity Quote Request

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Fortix ID Request

Your Information

Name*

Business Name

ABN

Best Contact Number*

Email*

Website

Address*

Are you currently insured?*

Yes
No

Current Policy Expiry Date

Current Insurer

About Your Business

Occupation*

Normal Duties*

Gross professional fee income for last 12 months

Estimated professional fee income for next 12 months*

Which states do you receive client fees from?*

Percentage in NSW*

Percentage in VIC*

Percentage in QLD*

Percentage in SA*

Percentage in WA*

Percentage in TAS*

Percentage in NT*

Percentage in ACT*

Percentage Overseas*

If overseas work, please advise the type of work and the countries where work is undertaken?*

NSW Stamp Duty Declaration

Are you a small business Individual / Partnership / Company and/or Trust, which is carrying on a business, and the business has an aggregated turnover of less than $2 million*

Yes
No

Aggregated turnover is your Australia wide annual turnover plus the annual turnovers of any business entities that are your affiliates or are connected with you.

Click here to read more about this exemption

Limits of Cover

What limit of Professional Indemnity cover do you require?*

What limit of Public Liability cover do you require?*

None
$10,000,000
$20,000,000
Other

If other, please advise limit required?*

Risk Management

Do you engage sub-contractors or sub-consultants?*

Yes we do
No, not at this stage but maybe in the future
No and no plans to

If yes, please provide further details as to the nature of work undertaken by these Contractors or Consultants*

Do you require each Contractor, Sub-Contractor or Consultant to have their own Professional Indemnity cover in place?*

Yes we do
No we dont
I am unsure

What is your annual payments to sub-contractors?

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
No

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

Yes
No

If Yes, please provide further information*

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

Yes
No

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

Yes
No

If Yes, please provide further information*

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

Yes
No

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

Yes
No

If Yes, please provide further information*

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

Yes
No

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

Yes
No

If Yes, please provide further information*

Other Insurances

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

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*

How did you hear about Webber Insurance?*

Web Search
Referred by Someone
A Building Designer Association
Social Media
Previous / Existing Client
Other

If other, please advise*

We appreciate referrals. Please let us know who provided you with our details*

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:*

Financial Services Guide
Privacy Policy
Duty of Disclosure
Terms of Engagement

Signature

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

Signature

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Professional Indemnity Quote Request

Your Information

About Your Business

NSW Stamp Duty Declaration

Limits of Cover

Risk Management

Claims Experience

Other Insurances

Additional Information

Important Information

Declaration

Signature

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