Professional Indemnity Questionnaire

Business Details

Name of firm:
ABN
ACN
Email:
Address
State/Territory
Postcode
Phone #
Fax #
Mobile #

Date of commencement of:

Current Firm
Cessation of Former Firm(s)

Names in full of all Partners/Directors/Principals

Name(1)
Qualifications(1)
Length of time that the position has been held(1)
Date Obtained(1)
Name(2)
Qualifications(2)
Length of time that the position has been held(2)
Date Obtained(2)
Name(3)
Qualifications(3)
Length of time that the position has been held(3)
Date Obtained(3)
3) Is cover required for any previous business entity?
If yes, please provide details

Please specify a headcount number for the following:

Partners/Directors/Principals
Qualified Staff
Other Staff
Does the firm enter any written agreements or letters of appointment?
Does the firm issue any literature, etc. describing the services offered?
If yes, please upload examples in email or print form

Please give the total annual gross fees for the current  year and an estimate for the coming 12 month period.

Current Year

Australia
Overseas

Coming Year

Australia.
Overseas.

Please provide details of the five largest contracts undertaken in the past 5 years

Title of contract(1)
Fee(1)
Title of contract(2)
Fee(2)
Title of contract(3)
Fee(3)
Title of contract(4)
Fee(4)
Title of contract(5)
Fee(5)

Please provide an approximate percentage of your activities, based on fee income, applicable to each State/Territory

NSW
VIC
QLD
SA
WA
TAS
NT
ACT
OVERSEAS
Is any of the work for which you are responsible subcontracted?
If yes, do they carry professional indemnity insurance?
What % of income is paid to such persons?
Are you involved in any process of manufacture, construction, alteration, repair, installation or sale or supply of materials and equipment, other than in a pure consultancy capacity as previously described?
If yes, please provide details below
Has the firm or any of the Partners/Directors/Principals ever been a member of a consortium or a joint venture?
If yes, please provide details below:

Do you require this insurance to provide for legal actions brought:

Only in the courts of Australia/New Zealand
In courts anywhere in the world excluding USA & Canada
Is the firm represented in the USA or Canada and any of their teritories?
If yes, please provide details:
Does the firm or any Partners/Directors/Principals have an association with or financial interest in any other firm or organisation?
If yes please provide details

Please provide the following details, if applicable


Name of current insurer/s
Limit of indemnity
Excess Applicable
Expiry Date
Premium

Has any insurer ever, in respect of the firm and or the partners/directors/principals and/or its former partners/directors/principals:

Declined to insure?
Imposed special terms?
Cancelled or avoided a policy?

Has any insurer ever, in respect of the firm and or the partners/directors/principals and/or its former partners/directors/principals:

Has any claim for professional negligence, error or omission evern been made against the firm and or partners/directors/principals or employees and or their predecessors in the Firm whether insured or not?
If yes, please supply an attached claims addenum here
Are any of the Partners/Directors/Principals or employees after enquiry aware of any circumstances which are likely to give rise to a claim against the Firm or its predecessors in business or any of its present or former Partner/Directors/Principals or employees
For what limits of indemnity do you require quotation
What policy excess do you require?