Person selected will receive initial Email (with link to pass on to client)
Person selected will receive Email when client completes form
Selections effects the automated emails created when client completes form to Pacific:
Renewal - Pacific
Will email Pacific the client completed Proposal as a RENEWAL
And CC servicer
Renewal - All other Insurers
Will NOT email Pacific. The client completed Proposal will only be emailed to servicer
Will NOT email Pacific the Proposal as And will allow you to select if you want to create M-Files lead
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)
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 2019. 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 attach below a company profile or any other supporting information which may assist us in gaining a better understanding of your professional business practice.
Please list all professional services provided and allocate an approximate percentage of your fee income for each: (MUST EQUAL 100%)
9. Sub Consultants
10. Insurance History
11. Past Applications
Have you ever had a Professional Indemnity insurer:
12. Claims History
Please give brief description, location, contract value and fees derived from the three largest contracts undertaken during the last 5 years.
14. Other Business Interests
Are you or have you or any parent, subsidiary or other related entity either: (i) engaged in, or: (ii) have or had a controlling share of an entity engaged in:
15. Cover Required
If you would like a quote on multiple limits please select more than one
Additional Documents & Comments
Please attach a copy of your CV and any additional company information you feel may assist us in understanding your professional business practice
Accepted file types: jpg, gif, png, pdf, Max. file size: 2 MB.
Drop files here or
Time Stamp 06/06/2023
User IP Stamp 188.8.131.52
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