CovComplete - Playgrounds PI

Your Duty of Disclosure

Before you enter into an insurance contract with an insurer, you have a duty to disclose to the insurer every matter that you know, or could reasonably be expected to know, that is relevant to the insurer’s decision whether to accept the risk of the insurance and, if so, on what terms. Your duty is not limited to answering specific questions in a proposal. Any additional relevant matters must also be disclosed. You have this duty until the insurer agrees to cover your risk. You have the same duty before you renew, extend, vary or reinstate an insurance contract.

Your duty however does not require disclosure of a matter:

that diminishes the risk to be undertaken by the insurer;
that is of common knowledge;
that your insurer knows, or in the ordinary course of its business, ought to know; or
as to which compliance with your duty is waived by the insurer.

For eligible contracts (where a natural person is purchasing Motor Vehicle, Home, Contents, Accident & Sickness, Consumer Credit or Travel Insurance) the insurer may provide you with a copy of all information previously disclosed to them by you, and request you provide updated information where required. If you do not advise of any changes to previous information, the insurer will be under the impression that no changes have occurred to the risk.

Non-disclosure

If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce his liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of voiding the contract from its beginning.

Privacy

At Coverforce, we are committed to protecting your privacy in accordance with the Privacy Act 1998 (Cth). A copy of our Privacy Policy is located on our website www.coverforce.com.au or alternatively you can obtain a copy from our Privacy Officer by emailing compliance@coverforce.com.au

Please note that insurers have their own disclosure requirements. We recommend you review the disclosure notice in the proposal form to ensure you have correctly adhered to the insurer’s requirements.

To request a quote, simply fill in the questions outlined in the form below. Our team will review the form and be in touch with you shortly.

All fields marked with an * are mandatory.

Practice Details

Please list the full name of all current entities to be insured. It is essential to specify the names of all entities including trading names, service, administrative or nominee companies and subsidiaries that you wish to be covered by this policy.

Entity Name *

Date Established *

ACN *

ABN *

In respect of the current practice and any of its principals / partners / directors, have any professional indemnity insurers declined a proposal? *

YesNo

Please provide details *

In respect of the current practice and any of its principals / partners / directors, have any professional indemnity insurers imposed special or unusual terms? *

YesNo

Please provide details *

In respect of the current practice and any of its principals / partners / directors, have any professional indemnity insurers declined to continue the practice's insurance? *

YesNo

Please provide details *

In respect of the current practice and any of its principals / partners / directors, have any professional indemnity insurers cancelled the practice's insurance? *

YesNo

Please provide details *

In respect of the current practice and any of its principals / partners / directors, have any professional indemnity insurers denied indemnity for a claim? *

YesNo

Please provide details *

Practice Details (Staff)

Please provide the details of the contact person and office below. If the practice has any additional offices, please select 'add office' to include more information.

Name *

Position *

Contact Number *

Email Address *

Address *

Office Number *

Please provide the details of each principal / partner / director below.

Individual's Name *

Age *

Years in this role *

Qualifications *

Institute / Association Memberships *

Please provide the details of the practice's staff (excluding principal / partner / director) below.

Number of qualified professionals *

Number of other technical staff *

Number of other staff *

Please list the professions of the technical staff *

Total number of staff *

Has any principal / partner / director or staff member ever been subject to disciplinary proceedings for professional misconduct? *

YesNo

Please provide details *

Do you require principal's previous business cover? *

YesNo

Principal / Director Name *

Name of previous unrelated practice *

Date principal / director left *

Are you planning any substantial changes in your activities or are there any new operations contemplated during the next 12 months *

YesNo

Please provide details of changes *

Has the practice or any principal / partner / director been a member of any join venture? *

YesNo

Please provide details of joint venture *

Please provide details of the practice's professional development program *

Please provide details of the practice's risk management procedures *

Practice Details (Professional Fees)

Please provide details of the professional fees earned for the last 12 months (Excluding GST)

Australia ($AUD)

Overseas ($AUD)

Please provide details of the estimated professional fees for the next 12 months (Excluding GST)

Australia ($AUD)

Overseas ($AUD)

Please provide a breakdown of professional fees earned for the last 12 months (Note: If you are a new practice, please provide an estimate).

NSW (%)

VIC (%)

QLD (%)

SA (%)

WA (%)

TAS (%)

NT (%)

ACT (%)

Overseas (%)

Do you engage consultants, sub-contractors or agents? *

YesNo

Do they need to carry their own professional indemnity insurance? *

YesNo

Professional fees paid to sub consultants for the last 12 months (Excluding GST) *

Has the business ever undertaken, or likely to undertake work overseas?

YesNo

Practice Details (Professional Fees continued)

Please specify other activities *

% of professional fees (Other) *

% of professional fees (Acoustical Engineering) *

% of professional fees (Architecture) *

% of professional fees (Building Design) *

% of professional fees (Building Surveying) *

% of professional fees (Chemical Engineering) *

% of professional fees (Civil Engineering) *

% of professional fees (Construction Management) *

% of professional fees (Drafting) *

% of professional fees (Electrical Engineering) *

% of professional fees (Engineering Surveying) *

% of professional fees (Environmental Consultancy) *

% of professional fees (Environmental Engineering) *

% of professional fees (Fire Design Services) *

% of professional fees (Fire Engineering) *

% of professional fees (Geotechnical/Soil Engineering) *

% of professional fees (Heating & Ventilating/Air-Conditioning Engineering)

% of professional fees (Hydraulic Design Services) *

% of professional fees (Hydraulic Engineering) *

% of professional fees (Interior Design) *

% of professional fees (Land Surveying) *

% of professional fees (Landscape Architecture) *

% of professional fees (Marine Engineering) *

% of professional fees (Marine Surveying) *

% of professional fees (Mechanical Engineering) *

% of professional fees (Mining Engineering) *

% of professional fees (Nuclear Engineering) *

% of professional fees (Project Management) *

% of professional fees (Quantity Surveying) *

% of professional fees (Structural Engineering) *

% of professional fees (Town Planning) *

Activities and Projects

Please specify what other activity *

% of practice activity (Other) *

% of practice activity (Aquatic Centres) *

% of practice activity (Bridges/Tunnels) *

% of practice activity (Commercial Buildings) *

% of practice activity (Commercial Tenancy Fit Out) *

% of practice activity (Dams) *

% of practice activity (Domestic Land Surveying) *

% of practice activity (Energy Rating) *

% of practice activity (Environmental Impact Assessments & Audits) *

% of practice activity (Expert Witness) *

% of practice activity (Feasibility Studies, Investigations or Reports) *

% of practice activity (Foundations & Underpinning) *

% of practice activity (Habours & Jetties) *

% of practice activity (Heritage Buildings) *

% of practice activity (High Rise Buildings)

% of practice activity (Hotels/Motels/Pubs) *

% of practice activity (Individual Dwellings) *

% of practice activity (Industrial Buildings) *

% of practice activity (Low Rise Buildings - up to 5 storeys) *

% of practice activity (Mechanical Plant and Bulk Handling Equipment) *

% of practice activity (Mines) *

% of practice activity (Modular Buildings) *

% of practice activity (Oil & Gas Pipelines *

% of practice activity (Petrochemicals, Refineries, Fertilisers) *

% of practice activity (Pollution Control Equipment) *

% of practice activity (Pre-Purchase Building Inspections) *

% of practice activity (Retail Shops) *

% of practice activity (Roads) *

% of practice activity (Schools, Hospitals, Municipal Buildings) *

% of practice activity (Sewerage, Water Systems - Commercial) *

% of practice activity (Sewerage, Water Systems - Domestic) *

% of practice activity (Sports Centres/Clubs) *

% of practice activity (Subdivisions) *

% of practice activity (Teaching/Lecturing) *

% of practice activity (Town Planning) *

% of practice activity (Waste Disposal, Treatment or Management) *

Please provide details of the 5 largest projects undertaken during the last 5 years. Note: If you are a new practice, please indicate the scope of works anticipated.

Project 1 *

Location *

The pratice's role *

Project Value *

Professional Fees *

Has the practice or any related entity ever engaged in or had a share of an entity engaged in actual construction, fabrication, erection or any for of building contracting? *

YesNo

Please list the names of the other entities involved and describe the relationship *

Has the practice or any related entity ever engaged in or had a share of an entity engaged in real estate development *

YesNo

Please list the names of the other entities involved and describe the relationship *

Has the practice or any related entity ever engaged in or had a share of an entity engaged in manufacture, sale, or distribution of any product or process or patented production process? *

YesNo

Please list the names of the other entities involved and describe the relationship *

Important Information

Have any claims or allegations of negligence or breach of professional duty been made in the last 10 years against the practice (or any of its 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 night give rise to claim? *

YesNo

Date Notified *

Name of Insurer *

Name of Claimant / Potential Claimant *

Description of problem *

Amount Paid or Outstanding *

Finalised or Outstanding *

Are there any additional claims or allegations of negligence or breach of professional duty against the practice (or any of its predecessors in business or any prior practice of any of their present or former partners, principals or directors) or are there circumstances that may give rise to a claim which have NOT been included in the previous question? *

YesNo

Please provide details *

If you require cover for incorporated entities the practice previously conducted, please provide details:

Name

Date Established

Date name changed or ceased trading

Has the practice ever entered into a Collateral Warranty? *

YesNo

Does the practice require cover for the Collateral Warranty exposure? *

Does the practice currently hold Professional Indemnity Insurance? *

YesNo

Current Insurer *

Policy Due Date *

Annual Premium Paid *

What date did the practice last hold Professional Indemnity Insurance *

Please specify