Professionals Australia Engineers PI Proposal Form

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  • IMPORTANT NOTICE ABOUT THIS POLICY

  • Claims Made Policy

    This policy is a claims made policy of insurance. This means that the policy covers you for claims made against you and notified to the Insurer during the period of insurance. The Policy does not provide cover in relation to:

    • events that occurred prior to the retroactive date, if any, specified in the Policy;
    • claims notified or arising out of circumstances notified under any previous policy (whether made or issued by the Insurer or any other insurer);
    • claims made against you prior to commencement of the period of insurance;
    • claims arising out of claims and circumstances noted on the proposal form for the current period of insurance or on any previous proposal form;
    • subject to what is said in the next paragraph, claims made after expiry of the period of insurance even though the event giving rise to the claim may have occurred during the period of insurance.

    However, where you give notice in writing to the Insurer of facts that might give rise to a claim against you as soon as reasonably practicable after you become aware of those facts but before expiry of the period of insurance, the policy will, subject to its terms and conditions, cover you notwithstanding that a claim is only made after expiry of the period of insurance.

    Your Duty of Disclosure

    Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contracts Act 1984, to disclose to the insurer every matter which you know, or could reasonably be expected to know, is relevant to the insurer’s decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to us before you renew, extend, vary or reinstate a contract of insurance.

    Your duty however does not require disclosure of a matter:

    • that diminishes the risk to be undertaken by the insurer
    • that is common knowledge
    • that the insurer knows or, in the ordinary course of business as an insurer, ought to know as to which compliance with your duty is waived by the insurer.

    Non-Disclosure

    If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from it’s beginning.

  • 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

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  • 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 2021. 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. Industry Breakdown

  • To enable Insurers to better appreciate the type of work which your fi rm or company has been involved in, please state as an approximate percentage your gross professional fees in the last year or if none, your estimated fees for the current year) derived from the following types of work:

  • Exceeding 3 floors and not otherwise classified

  • 10. Sub Consultants

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  • 11. Insurance History

  • 12. Past Applications

  • Have you ever had a Professional Indemnity insurer:

  • 13. Claims History

  • 14. Contracts

  • Please give brief description, location, contract value and fees derived from the three largest contracts undertaken during the last 5 years.

  • 15. 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:

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  • 16. Cover Required

  • If you would like a quote on multiple limits please select more than one

    Select more than one if you would like a quote on multiple limits

  • (N.B. Your policy will be subject to a minimum excess)

  • 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
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf.

  • 17. DECLARATION

  • I/We hereby declare that:
    • My/Our attention has been drawn to the Important Notice accompanying this Proposal form and further I/we have read these notices carefully and acknowledge my/our understanding of their content by my/our signature/s below.
    • The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this Proposal form and the inception date of the insurance to which this Proposal relates I/we shall give immediately notice thereof.
    • I/We authorise Austbrokers Countrywide to collect or disclose any personal information relating to this insurance to/from any other insurers or insurance reference service. Where I/We have provided information about another individual (for example, an employee, or client),
    • I/We declare that the individual has been or will be made aware of that fact and the section in the Policy on “The way we handle your personal information”.
    • I/We also confirm that the undersigned is/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this Proposal form and I/we complete this Proposal form on their behalf.
    • I/We declare that where we declare our turnover less than $2million that I/we are a small business eligible for the exemption from the requirement to pay duty on certain types of insurance under section 259B of the Duties Act 1997 (NSW).
  • Agreeing to the form does not bind the practice or Insurers to complete the insurance.
    • To be signed by the Chairman/President/Managing Partner/Managing Director/Principal of the association/ partnership/company/practice/business.
    • It is important that the signatories to the Declaration are fully aware of the scope of this insurance so that all questions can be answered. If in doubt, please contact us since non-disclosure may affect an Insured’s right of recovery under the policy or lead to it being voided.
  • Time Stamp 16/01/2021
    User IP Stamp 185.93.229.10

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By purchasing online:

•  You are expected to self-manage your policy.
•  There is no advice provided by Austbrokers Countrywide.
•  You will need to manage your own claims directly with Austbrokers Life Solutions by calling 1300 161 635.
•  If you need to make changes to the policy, you will need to contact Austbrokers Life Solutions on 1300 161 635.

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By purchasing online:

•  You are expected to self-manage your policy.
•  There is no advice provided by Austbrokers Countrywide.
•  You will need to manage your own claims directly with CHUBB by calling 1800 803 548.
•  If you need to make changes to the policy, you will need to contact CHUBB on 1800 803 548..

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By purchasing online:

•  You are expected to self-manage your policy.
•  There is no advice provided by Austbrokers Countrywide.
•  You will need to manage your own claims directly with CGU by calling 1300 306 083.
•  If you need to make changes to the policy, you will need to contact CGU on 1300 306 083.

CLICK TO CONTINUE

You are about to leave our site

By purchasing online:

•  You are expected to self-manage your policy.
•  There is no advice provided by Austbrokers Countrywide.
•  You will need to manage your own claims directly with CGU by calling 1300 306 083.
•  If you need to make changes to the policy, you will need to contact CGU on 1300 306 083..

CLICK TO CONTINUE

You are about to leave our site

By purchasing online:

•  You are expected to self-manage your policy.
•  There is no advice provided by Austbrokers Countrywide.
•  You will need to manage your own claims directly with CGU by calling 1300 306 083.
•  If you need to make changes to the policy, you will need to contact CGU on 1300 306 083..

CLICK TO CONTINUE