Information Technology Combined Professional Indemnity & Liability Insurance

Business Details

Insured Name (Legal Entity Name)*

Telephone*

Contact Name*

Email*

Date of Establishment*

Website

ABN/ACN*

Number of staff including principals and employees*

Head Office Address*

Street Address City State Postcode

Address of all other locations (if any) from which the insured operates

Past Claims

Has any claim been brought against you arising from the performance of your business activities or has anyone threatened to bring such a claim?*

Yes

No

Are you aware of any shortcoming in your work for a client which is likely to lead to a claim against you?*

Yes

No

You have answered yes to a claim being brought against you from your performance of business activities. Please provide more details below.*

You have answered yes to being aware of a shortcoming in your work for a client. Please provide more details below*

Has any proposal in respect of the risks to which this form relates ever been declined or has any such insurance ever been cancelled or renewal refused?*

Yes

No

Has there been any Public/Products liability claims, whether successful or not, against you in the last 5 years?*

Yes

No

You have answered yes to having a proposal being declined or insurance policy cancelled or renewal refused. Please provide more details below*

You have answered yes to having a claim against you in the last 5 years. Please provide details below.*

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Information Technology Combined Professional Indemnity & Liability Insurance

Business Details

About Your Work

Past Claims