On-line Professional Indemnity Insurance Renewal



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 renewal 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.


1. Expiring Policy Number:
2. Total number of:
2a. Qualified staff-including Principals (please specify professional discipline):
2b. Other technical staff
2c. Non-technical staff (including typists, receptionists etc.)
Total of all staff
Fee Income
3a. Gross professional fees for the last 12 months.
Include fees paid to sub-consultants appointed by you. Exclude fees collected for disbursement to consultants appointed by your client together with travelling, accommodation or similar expenses reimbursed by your clients.
Australia $ Overseas $
3b. Estimated gross professional fees for the next 12 months.
Include fees paid to sub-consultants appointed by you. Exclude fees collected for disbursement to consultants appointed by your client together with travelling, accommodation or similar expenses reimbursed by your clients.
Australia $ Overseas $
3c. Please provide a percentage breakdown of the fee income disclosed in Question 3a by State or Territory
NSW  VIC  QLD  SA  WA  TAS  NT  ACT  Overseas
%  %  %  %  %  %  %  %  %
Your Professional Activities
4. Nature of your Business
Have there been any changes in the nature of your business since your last proposal was submitted to us?
Yes No
If yes, please provide details:
Categorise the activities undertaken and indicate the percentage of your total income each activity represents:
Activity Percentage of Total Income
%
%
%
%
Claims and Circumstances
5a. Are there any Claims made or Claims circumstances that have not been reported to us?
Yes No
If yes, please provide details:
Claimant Nature of Problem Estimate Current Status
$
$
$
5b. Has any Principal or staff member ever been subject to disciplinary proceedings for professional misconduct?
Yes No
If yes, please provide details:
Name of Practice and
Principal/Staff member
Claimant Nature of Problem Amount Paid and/or
Outstanding
$
$
$
Optional Extensions - Entity Cover Employment Practices Liability
6. Do you require Employment Practices Liability Cover, subject to additional premium?
Yes No
Your Risk Review
7. As you have provided underwriting information to us in your previous proposal form, all the questions previously asked are not required to be completed. This form that you have been asked to complete has been shortened for your convenience.

Please outline below any changes to your business or professional practice that are not mentioned in this form, that have occurred since you have been insured with us. This should include any changes to the structure of your business, any alterations to the type of services your firm provides or any other changes which may affect the insurance risk.


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
ABN:
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:
Country: