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.
We may ask you additional information about this.
Professional fees earned for last 12 months (Excluding GST):
Estimated professional fees for the next 12 months (Excluding GST):
(If a new practice, provide an estimate)
Please make sure your total professional fee breakdown is equal to 100%.
Please make sure your total activities are equal 100%.
Please make sure the areas of work are equal to 100%.
Sum Insured & Insured Property
Please Note: Subject to the information provided, we may be in touch to clarify or obtain further information in relation to your contract.
Provide the current percentage of Activities:
Provide the current percentage of Territorial Limits:
Period of Insurance:
Sub Limits:Please complete below if you require specific limits or tick the box for the Insurers standard limits.
- OR -
What are the current Policy Expiry Dates (if applicable):
Include CV / qualifications for startup practices or a Policy Schedule / Certificate for your current policy.
I/We hereby declare that:
I/We have read and understood the important notices available from the following link.
The persons noted below 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 proposal and that I/we complete this proposal on their behalf.
The above statements are true, that I/we have not suppressed or misstated any facts, and that should any of the information given by me/us alter between the date of this proposal and the inception date of the insurance to which this proposal relates I/we will give immediate notice thereof.
Enquiry should be made of all principals/partners/directors and senior staff to ensure full disclosure.
Agreeing to the above does not bind the practice to accept the insurance or the insurers to provide a quotation.