Person selected will receive initial Email (with link to pass on to client)
Person selected will receive Email when client completes form
1. Business Details
Full legal name of each natural person & incorporated body to be insured as well as any unincorporated business or trading names
2. Contact Details
3. Particulars of Principals
4. Staff Number
5. Membership Details
6. Fee Income
Please provide the amount of gross incomes/fees earned by the applicant: (in $Aud)
Gross turnover (including all revenue from sales, manufacture or installation)
Please provide a percentage breakdown of the fee income disclosed above by by state and/or territory.
DECLARATION TO CLAIM THE NSW DUTIES ACT 1997 SMALL BUSINESS STAMP DUTY EXEMPTION:
This declaration covers policies effected or renewed during the year ended 30 June 2020. You are a small business for the current year if you carried on a business in the previous year and your aggregated turnover for that previous year was less than $2million and/or your aggregated turnover for the current year is likely to be less than $2million. For more information, visit www.revenue.nsw.gov.au/taxes/insurance/exemptions
To claim NSW Stamp Duty Exemption agree to declaration below.
7. Overseas Activities
8. Professional Services Breakdown
Please advise the approximate percentage breakdown of the applicant’s professional services: (MUST EQUAL 100%)
9. Providing Services or Products
Do you provide any of the following Products, Services or Applications?
10. Insurance History
11. Past Applications
Have you ever had a Professional Indemnity and/or liability insurer:
12. Claims History
13. Risk Management
Please give brief description, location, contract value and fees derived from the three largest contracts undertaken during the last 5 years.
15. Cover Required
If you would like a quote on multiple limits please select more than one
Time Stamp 06/06/2023
User IP Stamp 188.8.131.52
Please don't close the browser after clicking SUBMIT.
The form may take several minutes to process.