Contact Details

Insured Name *

Contact *

Phone *

Email Address *

ABN

Date of Establishment

Address *

Street address *Street address line 2

City *

State *Please selectACTNSWNTQLDSATASVICWA

Postcode *

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Limits of Indemnity

Limit of indemnity for Professional Indemnity Insurance *$1,000,000$2,000,000$5,000,000$10,000,000Other

Limit of Indemnity for Public/Products Liability Insurance *$5,000,000$10,000,000$20,000,000Other

Please specify

Please specify

Business Details

Please provide a detailed description of your professional business provided, which is required to be covered by this policy *

Total Number of Staff *

Total Number of Directors *

Total Number of Qualified Staff *

Please provide the following details for each of the Insured's principals, partners or directors *

Name

Age

Qualifications

Date Qualified

Years of Experience

Gross Revenue Earned

Last financial year's gross fees (AUD $) *

Please provide a breakdown of gross income by Professional Business for the headings listed below. List these in the text areas below in amounts of AUD$ or the percentage. *

Professional Business

Percentage Breakdown

Last financial year's gross fees

In respect of gross fees for the last financial year, please provide a breakdown by state *:

NSW

ACT

QLD

VIC

TAS

SA

WA

NT

Overseas

General Information

Does the company have operations outside of Australia? *

YesNo

Does the company have operations in the USA/Canada?

YesNo

Please provide further details

Have any Claims been made against the company for Professional negligence, error or omission in the last 5 years? *

YesNo

Please provide details

Income Breakdown

Please provide a breakdown of your gross fees/income by Professional Business for the last financial year by stating the relevant percentage. (Must total 100%) *

Engineer - Hydrologist / Water Conservation

Structural Engineering

Mechanical and/or Hydraulic Engineering

Electrical Engineering

Heat/Ventilation/Air-Conditioning Engineering

Civil Engineering

Mining Engineer

Chemical Engineering

Aerospace Engineering

Consulting Engineer

Acoustical Engineer

Environmental Engineer

Geotechnical/Soil Engineer

Project Management

Fire Protection Engineer

Other (Please specify)

Additional Information

Does the firm engage in sub-consultants? *

YesNo

Are the sub-consultants required to carry professional indemnity insurance? *

YesNo

 

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