Professional Indemnity
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7PROFESSIONAL INDEMNITY
INSURANCE PROPOSAL FORM
•
Answer all questions. Blanks &/or dashes, or answers ‘known to underwriters or brokers’
or ‘N/A’ are not acceptable & will delay consideration of this proposal.
•
If there is insufficient room to complete a question, please attach a signed & dated addendum.
•
Any documents attached to the proposal form are part of this proposal.
•
Where appropriate, please tick the yes or no box which best indicates your reply.
Your details
1. Name
a. Date(s) of
commencement
Full legal name of each natural person & incorporated body to be insured as well as any
unincorporated business or trading names.
D D
/
M M
/
Y Y
D D
/
M M
/
Y Y
D D
/
M M
/
Y Y
b. Are you registered for GST purposes?
No
Yes
What is your ABN?
c. If less than 5 years, please provide a resume of partners’/directors’ prior experience.
2. Address
a. Principal address
Postcode
Telephone no.
Facsimile No.
Mobile
Email address
Website address
b. Other locations
3. Particulars of all Principals
Years practicing as Principal
Name of Previous
Name of Principal
Age
Qualifications
Business Practices
Current Business
Previous Business
Practices
Practice
4. Principals’ previous business (incoming):
Name of Principal
Name of Principal’s previous business practice
Date Principal left that practice
D D
/
M M
/
Y Y
D D
/
M M
/
Y Y
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Parent category: Business