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.

Are you a current client of Austbrokers Countrywide?*

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

Are you a member of a professional association?*

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 on or after the year ended 01 January 2018. 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.
I declare that at the time the above policies are effected or renewed, I am/will be a “small business” as defined insection 259A of the Duties Act 1997 (NSW):

7. Overseas Activities

Have you ever undertaken work overseas for which you require to be insured under the policy?*
Do you, or have you ever had an office / branch outside Australia?*

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

Does the proposed insured use independent specialist consultants or sub-contractors to perform professional services on the Proposed Insured's behalf?*
Do you always insist that such specialist consultants or subcontractors hold and maintain professional indemnity insurance?*

11. Insurance History

Are you currently insured for professional indemnity?*
Have you ever been insured for professional indemnity?*

12. Past Applications

Have you ever had a Professional Indemnity insurer:
Decline a proposal?*
Decline to renew your insurance?*
Impose special terms?*
Cancel your insurance?*

13. Claims History

During the past 10 years has any Claim been made, or has negligence been alleged, against any entity or individual to be insured by this insurance (including any prior corporate entity and any of the present or former Principals), or have any circumstances which may give rise to a claim against any of these been notified to insurers?*
Are there any circumstances not already notified to insurers which may give rise to a Claim against any entity or individual to be insured by this insurance (including any prior corporate entity and any of the present or former Principals).*
Has any Principal or staff member ever been subject to disciplinary proceedings for professional misconduct?*

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:
Actual construction, fabrication, erection or any form of works contracting?*
Real estate development?*
Manufacture, sale or distribution of products or processes or patented production processes?*

ONLY where you act as a Project Manager or Construction Manager - Do you appoint or assume responsibility for sub-contractors?*
Have you ever designed or certified a building with a facade containing aluminium composite panels?*

16. Cover Required

If you would like a quote on multiple limits please select more than one
The Total Sum Insured that you require:*

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

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

17. Current CV, Additional Documents & Comments

Please attach a copy of your current 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, Max. file size: 256 MB.

    18. 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).
    You must agree to the form to proceed*
    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.
    Reset signature Signature locked. Reset to sign again
    Time Stamp 10/06/2023
    User IP Stamp 18.207.240.77

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    © 2022 AUSTBROKERS COUNTRYWIDE Countrywide Insurance Group Pty Ltd ABN 49 625 733 539 AFSL 511363

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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 COVERMORE by calling 1300 728 822.
    •  If you need to make changes to the policy, you will need to contact COVERMORE on 1300 728 822.

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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 EMERGENCE by calling 1300 799 562.
    •  If you need to make changes to the policy, you will need to contact EMERGENCE on 1300 799 562

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    Please select your profession

    1. Engineering & Construction Industry Project Manager

    2. Information Technology Project Manager

    3. Other Project Manager (including white collar, training, government, and change management)

     

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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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