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PI Application Form  
   
QBE Insurance (Australia) Limited

ABN 78 003 191 035

Professional Liability

Interactive Miscellaneous Risks Insurance Application

IMPORTANT: Please answer ALL questions fully. If there is insufficient space please provide details on your letterhead. Where provided tick (�) appropriate box to indicate answer. The Applicant will be referred to in this Application as “You” or “Your”.

 
A. Details of Applicant
1. Full name of all entities to be insured. (It is essential that you specify the names of all entities including service, administrative or nominee companies and subsidiaries that you wish to be covered by this Policy).
2. Address of head office or principal office.
State Postcode
Website www.
3. Date on which services commenced Current Insurance Expiry Date
4. Please supply total numbers employees
 
 
B. Business Details
5. Please provide the amount of gross income/fees for the following:
Your last financial year Your current financial year (estimate)
Australia Overseas
6. Please provide the approximate percentage of your activities (based on fee income) applicable to each State, Territory and Overseas.
NSW VIC QLD SA WA TAS NT ACT O/S
7. Please indicate which of the following categories best describes the main activities of the Business:
Agriculture / Environment / Forestry Please complete supplementary question S4, S5 and S29
Education or Child Care Please complete supplementary question S12
Education or Private Education Please complete supplementary question S32
Finance and/or Accounting Please also complete supplementary S31, S32, S33
Geological / Mineral Consultant Please complete supplementary question S 7 and S8
Hair Stylist / Barber Please also complete supplementary question S19
Health and Fitness Please also complete supplementary questions S15 and S16
Human Resources / Personnel Consultant Please also complete supplementary question S9 and S25
Industry Association Please also complete supplementary question S24
Insurance Please also complete supplementary question S2
Insurance Agency, Broking Services and/or Reinsurance Broking Services Please complete supplementary questions S30 and S31
Jeweller / Art / Antiques Please also complete supplementary question S13
Landscaper / Landscape Architect Please complete supplementary question S22
Loss Assessor / Adjustor Please complete supplementary question S3
Management / Business Consultant Please also complete supplementary question S11 and S28
Market Research Please also complete supplementary question S21
Marketing / Public Relations Consultant Please complete supplementary question S10
Private Investigator Please complete supplementary question S20
Real Estate Agent / Land or Building Surveying Please also complete supplementary question S6
Stock and Station Agent Please also complete supplementary question
Town Planning Please complete supplementary questions S1 and S23
Training Consultant / Facilitator Please complete supplementary question S26
Travel Agent Please complete supplementary question S14
Veterinarian Please complete supplementary questions S17 and S18
8. Please provide details of the precise nature of the activities of the Business:
 
 
C. Application for Cover
9. (a) Limit of Indemnity required
(b) Deductible requested (Each and every Claim)
(c) Optional Extensions:
• Aggregate Limit of Indemnity (Reinstatement) Yes No
• Fidelity $100,000 Sub-limit (Please answer question 10) Yes No
• Previous Business (Please answer question 11) Yes No
10. Has the applicant suffered any loss through the fraud or dishonestly of any employee? If “Yes”, please supply details: Yes No
11. Previous Business Cover To be completed only where the Applicant is applying for the Previous Business Extension
`
Name of principal, partner or director seeking Previous Business Cover Names(s) of previous business(es) Estimate Gross Income for previous business(es) for 2 financial/calendar year ends immediately prior to principal, partner or director leaving To the best of your knowledge, does the previous business(es) carry their own current Professional Indemnity Policy? Please provide details of the types of professional services offered by the previous business(es)
It is important that the claims and circumstances question within this Application Form fully reflect the claims and circumstances history of any prior Practice or previous business.
 
 
D. Claims Details
12. (a) Has any Claim been made, or has any civil liability been alleged in the last ten (10) years against the business or any of their predecessors in business or any prior practice of any of their present or former Partners, Principals or Directors, or have circumstances been notified to insurers that might give rise to a claim? If “Yes”, please supply the following details in respect to each matter. Yes No
Date Matter Notified Name of Insurer (If any) Name of Claimant or Potential Claimant Brief Description of Matter Amount Paid or Estimate of Potential Liability Is Matter Finalised or Outstanding?
(b) Are there any circumstances not already notified to Insurers which may give rise to a Claim against any applicant?
Name of Claimant or Potential Claimant Brief Description of Matter Estimate of Potential Liability
 
E. Risk Details
13. Has any applicant ever been refused this type of insurance or had similar insurance cancelled, or had an application of renewal declined, or had special terms imposed? If “Yes”, please supply details: Yes No
14. Has any applicant ever been subject to disciplinary proceedings for professional misconduct? If “Yes”, please supply details: Yes No
15. In the last 5 years, has any applicant been declared bankrupt? If “Yes”, please supply details: Yes No
16. In the last 5 years, has any applicant been the subject of administration proceedings? If “Yes”, please supply details: Yes No
17. In the last 5 years, has any applicant been convicted of any criminal offence (other than minor traffic convictions)? If “Yes”, please supply details: Yes No
18. Is any applicant connected or associated (financially or otherwise) with any other practice or business? If “Yes”, please supply details: Yes No
19. Has any other practice or business amalgamated or merged with you or have you purchased any other Practice or business? If “Yes”, please supply details: Yes No
20. Do you have the appropriate qualifications, licence or authorisation required to perform your professional duties? If “Yes”, please supply details: Yes No
21. Does any contract or client represent more than 50% of your annual work or fees? If “Yes”, please supply details: Yes No
22. (a) Are consultants, sub-contractors or agents engaged by you, required to carry their own professional indemnity insurance? If “Yes”, please supply details: Yes No
(b) Do you enter into any hold harmless agreements or otherwise waive any legal rights or entitlements which you may have against such consultants, sub-contractors or agents? If “Yes”, please supply details: Yes No
23. Do you envisage any substantial changes in your activities or are there any major new operations contemplated during the next 12 months? If “Yes”, please supply details: Yes No
24. Has any client refused payment or requested a refund of monies paid? If “Yes”, please supply details: Yes No
25. Other than New Zealand do you conduct business in any overseas country? If “Yes”, please provide approximate percentage breakdown by country: Yes No
26. Are verbal reports always confirmed in writing? If “Yes”, please supply details: Yes No
 
 
F. Supplementary Questions complete where instructed in Section B
S1 Does the applicant provide any project management or urban renewal services? If “Yes”, please supply details: Yes No
S2 Does the applicant provide life insurance risk advice only? If “Yes”, please supply details: Yes No
S3 Does the applicant undertake any private investigations? If “Yes”, please supply details: Yes No
S4 Does the applicant provide any services to Managed Investment Schemes or Agribusiness? If “Yes”, please supply details: Yes No
S5 Does the applicant provide any services in respect of non plantation logging? If “Yes”, please supply details: Yes No
S6 Does the applicant perform any inspection surveys? If “Yes”, please supply details: Yes No
S7 Does the applicant provide any services with respect to any Prospectus Reports? If “Yes”, please supply details: Yes No
S8 Does the applicant provide any services with respect to Oil and Gas? If “Yes”, please supply details: Yes No
S9. Does the applicant specialise in providing services with respect to the accountancy or legal fields? If “Yes”, please supply details: Yes No
S10 Does the applicant provide any services to sports persons, or actors? If “Yes”, please supply details: Yes No
S11 Does the applicant provide any Corporate Consultant services? If “Yes”, please supply details: Yes No
S12 Does the applicant undertake any outdoor activities, such as camps, excursions or student exchange programs? If “Yes”, please supply details: Yes No
S13 Does the applicant provide valuation services in respect of Fine Art, Collectors Items, or paintings? If “Yes”, please supply details: Yes No
S14 Does the applicant provide any services in respect of adventure travel, corporate accounts, sporting events, sporting tours or other specialist services? If “Yes”, please supply details: Yes No
S15 Does the applicant ensure that all instructors are accredited with the Fitness Institute of Australia? If “Yes”, please supply details: Yes No
S16 Does the applicant ensure that all classes are performed under the direct and active supervision of accredited instructors? If “Yes”, please supply details: Yes No
S17 Does the applicant provide services in respect of artificial insemination? If “Yes”, please supply details: Yes No
S18 Does the applicant provide services in respect of Equine/Bloodstock or racing animals? If “Yes”, please supply details: Yes No
S19 Does the applicant provide any piercing or tattoo services? If “Yes”, please supply details: Yes No
S20 Does the applicant provide services other than with respect to insurance investigations, or workers compensation matters? If “Yes”, please supply details: Yes No
S21 Does the applicant provide services to Publicly Listed companies? If “Yes”, please supply details Yes No
S22 Does the applicant provide any services in respect to golf courses? If “Yes”, please supply details Yes No
S23 Does the applicant provide any services with respect to works in capital cities? If “Yes”, please supply details: Yes No
S24 Does the applicant undertake any lobbying activities? If “Yes”, please supply details: Yes No
S25 Does the applicant participate in labour hire? If “Yes”, please supply details: Yes No
S26 Does the applicant provide training for any activity that would be considered hazardous, including but not limited to scuba diving, machinery safety and/or use, pilot or flying instruction? If “Yes”, please supply details: Yes No
S27 Does the applicant provide any business broking services? If “Yes”, please supply details: Yes No
S28 Does the applicant provide any investment advice, including mergers and acquisitions? If “Yes”, please supply details: Yes No
S29 Do any of your activities not relate to flora and fauna? If “Yes”, please supply details: Yes No
S30 Are you an Australian Financial Services Licence holder? If “Yes”, please supply details: Yes No
S31 Are you an Authorised Representative for an Australian Financial Services Licence holder? If “Yes”, please supply details: Yes No
S32 Are you a Registered Training Organisation? If “Yes”, please supply details: Yes No
S33 Does the applicant provide any services to Publicly Listed Companies, or Financial Institutions? If “Yes”, please supply details: Yes No
S34 Does the applicant hold a delegated lending authority? If “Yes”, please supply details If “Yes”, please supply details: Yes No
S35 Are lending funds sourced via solicitors mortgage funds or other mortgage funds? If “Yes”, please supply details: Yes No
 
 
1. Disclosure of Relevant Facts
Duty of Disclosure Under the Insurance Contracts Act 1984 (the Act), you have a Duty of Disclosure. You are required before you enter into, renew, vary, extend or reinstate your Policy, to tell us everything you know and that a reasonable person in the circumstances could be expected to know, is a matter that is relevant to our decision whether to insure you, and anyone else to be insured under the Policy, and if so, on what terms.
  • You do not have to tell us about any matter
    • that diminishes the risk
    • that is of common knowledge
    • that we know or should know in the ordinary course of our business as an insurer, or
    • which we indicate we do not want to know.
  • If you do not tell us
    If you do not comply with your Duty of Disclosure we may reduce or refuse to pay a claim or cancel your Policy. If your non-disclosure is fraudulent we may treat this Policy as never having worked.
 
2. Claims Made
This Policy operates on a ‘claims made and notified’ basis. This means that the Policy covers you for claims made against you and notified to us during the period of insurance.

The Policy does not provide cover in relation to:

  • acts, errors or omissions actually or allegedly committed prior to the retroactive date of the Policy (if such a date is specified)
  • claims made after the expiry of the period of insurance even though the event giving rise to the claim may have occurred during the period of insurance
  • claims notified or arising out of facts or circumstances notified (or which ought reasonably to have been notified) under any previous policy
  • claims made, threatened or intimated against you prior to the commencement of the period of insurance
  • facts or circumstances of which you first became aware prior to the period of insurance, and which you knew or ought reasonably to have known had the potential to give rise to a claim under this Policy
  • claims arising out of circumstances noted on the Application form for the current period of insurance or on any previous Application form.
Where you give notice in writing to us of any facts that might give rise to a claim against you as soon as reasonably practicable after you become aware of those facts but before the expiry of the period of insurance, you may have rights under Section 40(3) of the Insurance Contracts Act 1984 to be indemnified in respect of any claim subsequently made against you arising from those facts notwithstanding that the claim is made after the expiry of the period of insurance. Any such rights arise under the legislation only. The terms of the policy and the effect of the policy is that you are not covered for claims made against you after the expiry of the period of insurance.
 
 
3. Average Provision
The policy may provide that if a payment in excess of the limit of indemnity available under the policy has to be made to dispose of a claim, the insurer’s liability for costs and expenses incurred with its consent shall be such proportion thereof as the amount of indemnity available under this policy bears to the amount paid to dispose of the claim. You should familiarise yourself with our standard form of policy for this type of cover before submitting this declaration.
 
 
4. Privacy
QBE includes information about how we manage your personal information in our formal quotation terms, when issued. You can obtain a copy of the QBE Privacy Policy Statement from our website www.qbe.com.au or contact the Compliance Manager on 02 9375 4656 or email compliance.manager@qbe.com for further information.
 
 
Declaration and Authorisation
  1. I have received a copy of the Policy Terms and Conditions.
  2. I am authorised to complete and sign this insurance Application on behalf of the business.
  3. The responses provided are made based on information provided to me by the Principals, Partners and Officers of the business.
  4. I authorise QBE Insurance (Australia) Limited ABN 78 003 191 035 to give or obtain from other insurers or insurance reference bureaus or credit reporting agencies, any information about this insurance or any other insurance held by the business including this completed Application and the business’s claims history and credit history.
Signed, Partner, Principal or Director Date
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