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?
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.
Nature of your Business
Please express as a percentage of your gross professional fees relating
to the following fields of activity (if no actual fees, answer in relation to estimated fees)
a)
Structural Engineering
%
b)
Mechanical Engineering (including Hydraulic Engineering)
%
c)
Electrical Engineering
%
d)
Civil Engineering
%
e)
Chemical Engineering
%
f)
Construction and/ Project Management
%
g)
Town Planning
%
h)
Surveying - (i) Land
%
(ii)
Quantity
%
(iii)
Building
%
i)
Architecture
%
j)
Other
%
5.
To enable us to better appreciate the type of work which your firm or company has been
involve in, please state as an approximate percentage of your gross
professional fees for the last year (or if none, your estimated fees
for the current year) derived from the following types of work:
a)
Domestic Building (not including flats/town houses)
%
b)
Commercial Buildings (including flats/town houses)
%
c)
Institutional Buildings
%
d)
Industrial Buildings
%
e)
High Rise Buildings - exceeding 3 floors and not otherwise classified
%
f)
Town Planning
%
g)
Marine Surveys
%
h)
Bridges
%
i)
Tunnels
%
j)
Dams
%
k)
Mines
%
l)
Oil and Pipelines
%
m)
Refineries Handling Equipment
%
n)
Fair & Exhibition Grounds
%
o)
Subsurface Surveys, Ground Soil Testing
%
p)
Land Reclamation Schemes
%
q)
Other Activities
%
r)
Do you forsee any substantial changes in the percentages provided
in the above answers occurring during the next 12 months?
If yes, please provide details:
6.
Please give a brief description of the five largest projects you have been involved in over the last 5 years:
7.
Particulars of Principal
Resume/CV: If not contained on your website,
please copy & paste or email a brief resume for each Principal and/or
Director.
8.
Details of gross income/fees or commissions:
(a).
received / rendered during the last twelve months:
$
(b).
estimated for ensuing twelve months:
$
9.
Are any of your operations or clients located outside of Australia
If the answer to the above is "Yes", please specify which countries and percentage
of income deriving from each:
10.
Please state the approximate percentage of Your activities (based on income) applicable to each State, Territory and Overseas.
11.
Have you ever had a liability insurer:
(a)
Decline a proposal?
(b)
Impose special terms?
(c)
Decline to renew your insurance?
(d)
Cancel your insurance?
If the answer to any of the above is "Yes", please provide details:
12.
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?
13.
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?
14.
Has any principal or staff member ever been subject to Disciplinary Proceedings for professional misconduct?
If the answer to either of the above is "Yes", please provide details:
15.
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
16.
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 ?
(b)
Real estate development?
(c)
The manufacture, sale or distribution of any product or process or patented production process?
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.