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Energy Assessors - Quotation Request...

Please fill out the following form. Once completed, click the Submit button and a formal quote will be presented promptly.

This proposal is for Energy Assessors / Energy Raters only. If your business includes activities other than these, you need to complete one of our other forms which can cater for your multiple activities. Click here for access to other forms: Other Occupations

The Insurer will not cover you in respect of any property valuations.

NOTE: Make sure you put in your correct email address as a copy of this submission will be emailed to that address.

If you need advice, please call Liability Brokers: 1300 881 779


Client Details...

Insured Name:

Trading Name:

ABN: (if known)

Street Address:

Suburb/Town
    Postcode  

Telephone No:

Email Address:

 

If you have already spoken to someone in our office, please note their name here so that this form can be processed by them as they will know something about you already.

Brokers Name:

   

Professional Duties...

Please provide a breakdown of Your business activities.

Income by Type of Service - (must add up to 100%)

- Energy Assessing / Energy Rating

%

- Carbon Accounting

%

- Other Assessing, please give details below:

%

   

Area of Industry...

Please provide a breakdown of the areas of Your business activities.

Income by Area of Service - (must add up to 100%)

- Residential dwellings

%

- Schools, hospitals, municipal buildings & recreational centres

%

- Small commercial properties valued at $1,000,000 or less

%

- Medium commercial properties valued from $1,000,000 to $5,000,000

%

- Large commercial properties valued in excess of $5,000,000

%

- Other, please give details below:

%

Note: If your total fee income is from Residential Dwellings only ie. Residential dwellings 100%, we will rate you as Energy Assessors - Residential Only. (This will entitle you to a lower premium).

Do you agree to be rated as Energy Assessors - Residential Only?    Yes    No

   

Underwriting questions...

No. of directors / partners


No. of qualified assessors (other than directors)


.
Gross Fees last 12 months

Australia

If Nil, put in "0"    

USA/Canada

If Nil, put in "0"    

Elsewhere
If Nil, put in "0"    
.
Estimated Fees next 12 months

Australia

If Nil, put in "0"    

USA/Canada

If Nil, put in "0"    

Elsewhere
If Nil, put in "0"    

If you conduct business in overseas countries, please provide details below:

Please state the percentage of Your activities (based on income) applicable to each State
ACT NSW NT QLD SA TAS VIC WA
% % % % % % % %

 

Manual Risk Exposure...

If you are after Public Liability cover as well, we need this question to be answered, otherwise proceed to the next question.

Does your business involve any of the following?

1. Manual labour or manual tasks performed by yourself (apart from measuring)
2. The supervision of manual labour or manual tasks performed by other parties or
3. The responsibility of manual labour or manual tasks performed by other parties.
4. The training of others on how to perform manual tasks
Yes    No

If you answered "Yes", what duties do they perform?

   

Contractors...

Do you employ contractors, sub-contractors? Yes    No

If you answered "Yes", what duties do they perform?
Do You require cover for sub-contractors? Yes    No
If "NO", do You insist they carry their own insurance? Yes    No

   

Quote Required...

Please nominate the amount of covers you require:

Professional Indemnity  .    

Public Liability

$1,000,000 Not required
$2,000,000 $5,000,000
$5,000,000 $10,000,000
$10,000,000 $20,000,000

   

Insured's History...

Have you been previous insured for Professional Indemnity? Yes    No

If you answered "Yes", please provide the following details:
Insurers Name
Limit of Indemnity ($)
Expiry date

   

Have any claims ever been made against You, your predecessors in
business or of the present or past Partners or directors?

Yes    No

Are you aware, after enquiry, of any CIRCUMSTANCES which may
result in any claims against you, your predecessors in business
or any of the present or former Partners/Principals?
Yes    No


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Declaration...

By submitting this Declaration, the Applicant acknowledges:

  • they are authorised by each of the other Applicants to make this Declaration,
  • the contents of the Declaration are true and complete,
  • they are under a continuing obligation to immediately inform the insurer of any change in the particulars or statements contained in this Declaration or in the accompanying documents up until the contract is entered into,
  • they authorise the insurer to give or obtain from other insurers or insurance reference bureaus or credit reporting agencies, any information about this insurance or any other insurance held by the Applicant/s.

Name of person making this declaration: