To receive a confirmed quote, please complete the form below.
If you prefer to talk to a broker first, please call 1300-881-779
between 8.15am and 5.15pm E.S.T. business days.
If you have spoken to a broker in our
office, note their name here so that
this quote can be processed by them as they will know something about
ABN No.(if known)
Phone No. *
Do You require cover for any subsidiary or associated company?
If you answered "Yes" above, please give details.
What is your main occupation of the business?
Please give a description of your business activities.
Please nominate the amount of cover you require:
Gross revenue for last 12 months
Gross revenue for previous 12 months
Total number of employees
Is the company planning any redundancies or retrenchments in the next 12 months?
Please state the percentage of your turnover for each State
What percentage of your revenue is derived from Australia and/or New Zealand?
Does the business have operations or activities in the USA/Canada?
Is any Director, Officer or Employee of the Company aware of any facts or circumstances that may
affect the ability of the Company to meet its debts as and when they fall due or any change in
the financial position or capital structure of the Company that may materially affect the
performance of the Company?
Has any claim(s) been made against any Director, Officer or Employee of the Company for any matter
that is or would be the subject of this insurance policy in the past 5 years where the value of
all claims notified exceed $20,000 including current reserves, or is any Director, Officer or
Employee of the Company aware of any circumstance or incident which may give rise to a claim under
Upon enquiry, has the Company ever had any loss sustained through the fraud or dishonesty of any
Has your business, practice or any partner, principal or director ever been declined this type of
insurance, or had similar insurance cancelled, or had an application for renewal declined, or had
special terms or restrictions imposed?
Is the INSURED or COMPANY listed on the ASX or CHI X?
By submitting this Declaration, I/we declare and agree that:
Name of person making this declaration:
Duty of Disclosure - What you must tell us
Under the Insurance Contracts Act 1984 (the Act), you have a Duty of Disclosure.
You are required before you enter into, renew, vary, extend or reinstate your Policy, to tell us
everything you know and that a reasonable person in the circumstances could be expected to know,
is a matter that is relevant to our decision whether to insure you, and anyone else to be insured
under the Policy, and if so, on what terms.
You do not have to tell us about any matter
that diminishes the risk
that is of common knowledge
that we know or should know in the ordinary course of our business as an insurer, or
which we indicate we do not want to know.
If you do not tell us
If you do not comply with your Duty of Disclosure we may reduce or refuse to pay a claim or cancel
your Policy. If your non-disclosure is fraudulent we may treat this Policy as never having worked.
Claims Made Policy
The Professional Indemnity section of this Policy operates on a 'Claims made and notified' basis.
This means that the Policy covers you for Claims made against you and notified to us during the
Period of Insurance.
This Policy does not provide cover in relation to:
acts, errors or omissions actually or allegedly committed prior to the retroactive date of the Policy (if a date is specified);
claims made after the expiry of the period of insurance even though the event giving rise to the Claim may have occurred during the period of insurance;
claims notified or arising out of facts or circumstances notified (or which ought reasonably to have been notified) under any previous Policy;
claims made, threatened or intimated against you prior to the commencement of the period of insurance;
facts or circumstances of which you first became aware prior to the period of insurance, and which you knew or ought reasonably to have known had the potential to give rise to a Claim under this Policy;
Claims arising out of circumstances noted on the proposal form for the current period of insurance or on any previous proposal form.
Where you give notice in writing to the insurer or any facts that might give rise to a claim against
you as soon as reasonably practicable after you become aware of those facts but before the expire of
the period of cover, you may have rights under Section 40(3) of the Insurance Contracts Act 1984 to
be indemnified in respect of any claim subsequently made against you arising from those facts
notwithstanding that the claim is made after the expiry of the period of cover. Any such rights arise
under the legislation only. The terms of the Policy and the effect of the Policy is that you are not
covered for claims made against you after the expiry of the period of cover.