Professional Indemnity & Liability Insurance

Business Details

Insured Name (Legal Entity Name)*

Telephone*

Contact Name*

Email*

ABN*

Website

Date of Establishment*

Address*

Street Address City State Postcode Country

Please provide a detailed business description:

Business Description*

Please provide your actual total revenue or turnover for the previous financial year (enter '0' if not applicable):

Last Financial Year's Total Revenue*

Current Financial Year's Estimated Total Revenue*

Last Financial Year's Total Revenue Earned Overseas*

Current Financial Year's Estimated Total Revenue Earned Overseas*

For the purpose of calculating Stamp Duty please confirm the percentage of revenue earned in each state (enter '0' if not applicable, must add up to 100%):

ACT*

NSW*

NT*

QLD*

SA*

TAS*

VIC*

WA*

Overseas*

Hidden

Total percentage States*

Are you a small business eligible for exemption from paying NSW stamp duty on certain types*

Yes

No

The NSW Government has created a new small business stamp duty exemption in the Duties Act 1997 (NSW) (the Act) for eligible insurance acquired on or after 1st January, 2018.

If you are uncertain whether you are classified as a small business we recommend you seek professional advice and speak to your accountant or financial adviser.

Please select the limit of Indemnity required:

Professional Indemnity Limit Required*

Public & Products Liability Limit Required*

Past Claims

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 any claim been made against the Proposer or any principal, partner, director, consultant or employee in respect of the risks to which this proposal relates?*

Yes

No

You have answered yes to 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?*

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

Is any principal, director, partner, consultant or employee of the Proposer, after enquiry, aware of any circumstances which might give rise to a claim against the Proposer or his/her predecessors in business or any of the present or former partners, principals, directors, consultants or employees?*

Yes

No

Has the proposer, principal, director or partner ever been declared bankrupt or subject to any form of insolvency administration (e.g. liquidation or receivership) or been convicted of a criminal offence?*

Yes

No

You have answered yes to being aware of a claim being brought against you, your predecessors, employees or consultants. Please provide more details below.*

You have answered yes to being declared bankrupt or subject to any form of insolvency administration. Please provide details below.*

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Professional Indemnity & Liability Insurance

Business Details

About Your Work

Past Claims