On-line Professional Indemnity Insurance

Thank you for considering our on-line professional indemnity insurance service.   Because Greater National Group is an insurance broker, not an insurance company, we will process your application with major insurance companies in order to find the right professional indemnity for you.

Please fill in the following form as fully as possible, then click 'submit' at the end of the form.
You can use the TAB key to move to the next field. We will respond with your terms as soon as we have researched the market for the right available deals that fit your requirements.

1a. Please state the limit of indemnity required: $
1b. What excess do you wish to pay towards a claim?: $
2. Do you currently have professional indemnity insurance?
Yes No
If yes, please provide details below:
Expiry date:
Insurance company:
Indemnity limit: $
Excess: $
Premium: $
3. Please enter the full nature of the activities to be covered and type of advice given
4. Particulars of Principal:
Name of Principal Qualifications Professional Associations
Resume/CV: If not contained on your website, please copy & paste or email a brief resume for each Principal and/or Director.
5. Details of gross income/fees or commissions:
a. received / rendered during the last twelve months: $
b. estimated for ensuing twelve months: $
6. Are any of your operations or clients located outside of Australia
Yes No
If the answer to the above is Yes, please specify which countries and percentage of income deriving from each:
7. Please state the approximate percentage of Your activities (based on income) applicable to each State, Territory and Overseas.
%  %  %  %  %  %  %  %  %
8. Have you ever had a liability insurer:
a. Decline a proposal?
Yes No
b. Impose special terms?
Yes No
c. Decline to renew your insurance?
Yes No
d. Cancel your insurance?
Yes No
If the answer to any of the above is "Yes", please provide details:
9. During past years has any claim been made, or has negligence been alleged against you or any of the present or former Principals, or have any circumstances been notified to insurers which may result in a Claims?
Yes No
10. Are there any circumstances not already notified to insurers which may give rise to a Claim against you or any prior corporate practice or any of the present or former Principals?
Yes No
11. Has any principal or staff member ever been subject to Disciplinary Proceedings for professional misconduct?
Yes No
If the answer to either of the above is "Yes", please provide details below.
12. Total number of:
a. Qualified staff-including Principals (please specify professional discipline):
b. Other technical staff
c. Non-technical staff (including typists, receptionists etc.)
Total of all staff
13. Are you or have you or any parent, subsidiary or other related entity either: (i) engaged in, or; (ii) have or had a controlling share of an entity engaged in:
a. Actual construction, fabrication, erection or any form of sub contracting?
Yes No
b. Real estate development?
Yes No
c. The manufacture, sale or distribution of any product or process or patented production process?
Yes No
If the answer to either of the above is "Yes", please provide details:
(i) Names of the other entities involved, outlining their relationship to you:
(ii) Full details, including a description of the nature of the involvement:

Duty of Disclosure:
Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?
Yes No
If so, please provide details:
I/We hereby declare that:
My/Our attention has been drawn to the Important Notices accompanying this form and further I/we have read these notices carefully and acknowledge my/our understanding of their content. The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this form and the inception date of the insurance to which this relates I/we shall give immediate notice thereof. I/We authorise GNG and the Insurer to collect or disclose any personal information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact and the Privacy Policy. I/We also confirm that I/we am/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this form and I/we complete this form on their behalf.
Any other comments, requests or relevant information you need to add:
Contacting you about your quote:
In order to select the most appropriate cover for you, it may be important to discuss quote details in person. Please leave a contact phone number and best time to call to facilitate this.
Your full name:
Company/Business/Name of Applicant to be Insured: Date of Commencement
Are you registered for GST purposes?
Yes No
Your phone number (please include area code):
Your mobile phone number:
Best time(s) to call:
Please send my quote by (select at least one):
email phone fax mail
Your email address:
Your website address:
Your fax number:
Your postal address: