Apply For Engineers Professional Indemnity & Liability Insurance

Section 1: Contact Details

* Insured Name:

* Contact:

* Address:

* Telephone Number

Fax:

Web Address:

* Email:

ABN:

Date of Establishment:

Address of any other Business locations:

Section 2. Limits Of Indemnity

* Professional Indemnity $1,000,000
$2,000,000
$5,000,000
$10,000,000
Other Amount:

* Public/Products Liability $5,000,000
$10,000,000
$20,000,000
Other Amount:

Section 3: Business Description

* Please provide a detailed description of your professional business provided, which is required to be covered by this policy.

Section 4: Employee Information

* Total Number of Staff: * Total Number of Directors: * Total Number of Qualified Staff:

Please provide the following details for each of the Insured's principles, partners or directors:

Name: Age: Qualifications: Date Qualified: No. of Years experience: * Add Another? Yes No

Additional principles, partners or directors details:

Employee 2

Name:

Age:

Qualifications:

Date Qualified

No. of Years experience:

Add Another? Yes No

Employee 3

Name:

Age:

Qualifications:

Date Qualified:

No. of Years experience:

Section 5: Gross Revenue Earned

1. Last financial year’s gross fees:

* AUD $

Section 5a:

1. Please provide a breakdown of gross income by Professional Business for the headings listed below. List these in the text areas below in amounts of AUD$ or the percentage.

Professional Business Percentage Breakdown Last Financial Year's Gross Fees Current Financial Year's Gross Fees

2. In respect of gross fees for the last financial year, please provide a breakdown by state:

NSW

ACT

QLD

VIC

TAS

Overseas

Total

Captcha

Section 6: General Information

* Does the company have operations outside of Australia? Yes No

If Yes does the company have operations in the USA/Canada? Yes No

If YES please provide further details:

* Have any Claims been made against the company for Professional negligence, error or omission in the last 5 years? Yes No

If YES please provide further details:

Section 7: Income Breakdown

1.Please provide a breakdown of your gross fees/income by Professional Business for the last financial year by stating the relevant percentage. (Must total 100%)

Engineer - Hydrologist / Water Conservation

Structural Engineering

Mechanical and/or Hydraulic Engineering

Electrical Engineering

Heat/Ventilation/Air-Conditioning Engineering

Civil Engineering

Mining Engineer

Chemical Engineering

Aerospace Engineering

Consulting Engineer

Acoustical Engineer

Environmental Engineer

Geotechnical/Soil Engineer

Project Management

Fire Protection Engineer

Other (Please specify)

Total

Section 8: Additional Information

2. Does the firm engage in sub-consultants? Yes No

3. Are the sub-consultants required to carry professional indemnity insurance? Yes No

Thank you for your submission.
A representative will contact you within 24 hours with your Quotation.