Professional Indemnity Insurance  
NEW ZEALAND NATIONWIDE INSURANCE BROKER SERVICES
AucklandWellingtonChristchurchDunedinQueenstownGisborne
 
Professional Indemnity - Insurance PROPOSAL FORM
This form is designed to gather general information from which to present to various underwriters to obtain an indicative quote. You might have to provide further information in due course.

YOU WILL NEED TO PROVIDE A CV' FOR EACH DIRECTOR, PARTNER, PRINCIPAL OR IF YOU ARE A SOLE TRADER - A CV' CAN BE ATTACHED TO THIS FORM WHEN YOU GET TO SECTION 10.

If your Professional Indemnity requirements exceed the scope of this form, please contact us for direct personal assistance.
Terms and Conditions

Please ensure all required fields are filled in. They have been highlighted in red for your convenience.
PROPOSER DETAILS -
Section 1
   
In just a few words, please
describe the Proposer's Primary
Business:
   
  Please provide the full legal name of all entities to be insured under the Policy
   
What is the Trading Name?
[if different to the above question]
   
Is the Proposer a Company,
Partnership or Individual?
   
ABN or Other Business
Registration Number
   
Date of Establishment
of the Proposer's Business
   
Address of where your Business is situated - Head Office
[Include Postcode and State]
   
Postal address of Head Office if different from above
[Include Postcode and State]
   
Business Telephone
[Include Area Code]
   
Facsimile [Include Area Code]
   
Mobile
   
   
The Proposer's Website:
   

DIRECTORS, PARTNERS & PRINCIPALS DETAILS -
Section 2

Names Qualifications Date Qualified Years in Position
      This Practice Previous Practice
1
2
3
4
5
 

Staff Numbers

Full Time

Part Time

Directors, Partners, Principals

Professional Qualified Staff
(not included above)

Other Technical Staff

Non Technical Staff

Trainee Staff

Administration Staff

Other Staff

Total Staff

     
Does any Partner, Principal or Director of the Proposer have any connection or association (financially or otherwise) with any other similar business or practice?
If Yes
, please provide details.
   Yes No
   
GENERAL BUSINESS DETAILS -
Section 3
   
Please provide a precise
description of the Proposers'
business activities.
 
If the Proposer's business includes more than one activity, please categorise each activity, stating the approximate percentage of the fee income from such activity:
     

Activity

% of fee income

% of fee income

  Past 12 mths Est Next 12 mths

1

2

3

4

5

6

7

   
Have there been any substantial changes in the Proposer's business activities in
the past 12 months?
If Yes
, please provide details.
   Yes No
   
Does the Proposer expect any significant changes in business activities in the next 12 months?
If Yes
, please provide details.
   Yes No
   
Is the Proposer, a current financial member in good standing of a
Professional Association?
If Yes
, please provide details.
   Yes No
   
In the past 5 years, has the name
of the Proposer ever changed?
If Yes
, please provide details.
   Yes No
   
In the past 5 years, has the
Proposer purchased, merged or
amalgamated with another
similar business?
If Yes
, please provide details.
   Yes No
   

In the past 5 years, has the Proposer been involved in any
joint ventures?
If Yes
, please provide details.

   Yes No

   
Does the Proposer engage subcontractors?            Yes           No 
  If Yes, please state gross fees paid to Subcontractors:-
  Previous Financial Year Est. Current Financial Year Est. Next Financial Year
  $ $ $
       
Are subcontractors required to carry their own Professional Indemity Insurance?
If No
, please provide details.
   Yes No
   
Are verbal reports always confirmed in writing?
If No
, please provide details
   Yes No

Does the Proposer perform any work outside Australia, or work for clients located overseas?
If Yes
, please provide details
   Yes No

   

FOR SOLE PRACTITIONERS / PROPRIETORS ONLY - [if not, proceed to Section 5]
Section 4
   
Is the Proposer required to have a license or accreditation to practice the professional services for which cover is requested?    Yes No
   
If Yes, has the license or accreditation
been in force at all relevant times - being the period the Proposer has been in business?
If No
, please provide details.
   Yes No

   
Please provide details of the Proposer's Professional experience in this type of business.
   
Please provide details of the experience
of Senior Staff.
   
Please provide details of arrangements the Proposer has in place to ensure the business operates correctly during the Proprietor's temporary absences.
   

RISK MANAGEMENT PROGRAM -
Section 5

Does the Proposer have a documented Risk Management Program?
If Yes, what Date was it implemented
   Yes No
   
Is one Director - Partner - Principal
responsible for the implementation
and communication of the Program?
   Yes No
   
Does the Risk Management Program
include regular internel - external audits
or reviews?
   Yes No
   
Is the progam communicated to and
available to all staff?
If No, please provide details why not.
   Yes No


FINANCIAL DETAILS-
Section 6

Please state the Total of Annual Gross Professional Fees for:
         
  Location    Previous Financial Year    Est Current Financial Year    Est Next Financial Year
a) Australia $ $ $
b) Overseas (excluding North America) $ $ $
c) In North America
$ $ $
Total of a) b)
and c) above
$ $ $


In reference to the Annual Gross Professonal Fees stated above, please provide the "percentage breakdown":
       
  Location % of fee income % of fee income % of fee income
    Past 12 months Est Current Financial Year Est Next 12 Months
 

NSW  

%

%

%

 

VIC  

%

%

%

  QLD % % %
  SA %

%

%

  NT % % %
  WA %

%

%

  ACT % % %
  TAS % % %
  0/S % % %
  TOTAL % % %


Does any single client represent more
than 35% of the Proposers's total
business activities?
If Yes
, please provide details.
   Yes No

 
Please provide details of the Proposer's 5 largest clients if together those clients account for more than 50% of the Proposer's Annual Income:
   

Name of Client

Income $AUD

  Past 12 mths Est next 12 mths

1

2

3

4

5

TOTAL

     
CLAIMS HISTORY-
Section 7
 
 
After enquiry, have any claims for negligence or breach of professional duty been made against the Proposer or any of its Partners, Principals, or Directors.

  
  Yes      No  
     
  If Yes, give details below:-  
 
 
Date of Claim or Loss Brief Description of Claim Cost of Claim $ Current Status of Claim
 




After enquiry, is the Proposer or any of its Partners, Principals or Directors aware of any circumstances which has the potential to give rise to a claim in relation to negligence or breach of professional duty.

  
  Yes      No  
     
  If Yes, give details below:-  
 
 
Date First Notified Brief Description of Claim Name of Claimant Potential Quantum $
 


 
After enquiry, is the Proposer or any of its Parners, Principals or Directors or staff subject to disciplinary proceedings for professional misconduct?
If Yes, please provide details
   Yes No


PROPOSER'S INSURANCE HISTORY-
Section 8

  Does the Proposer currently have professional indemnity insurance? Yes       No 
If Yes, state:
Name of Insurer  Policy Number     
Renewal Date            Limit of Indemnity
Retroactive Date         
     
 
Has any Insurer, in respect of professional indemnity insurance ever:-:
 
 
a)   declined a proposal, refused renewal or terminated insurance?    Yes      No
 
 
b) required an increased premium or imposed special conditions?

   Yes      No
c) declined an insurance claim by the proposer or reduced its liability to pay a claim in full (other than by application of an excess)?

   Yes      No
 
 
  If Yes, to a), b) or c) please give details

LIMITS OF PROFESSIONAL INDEMNITY COVER REQUIRED:
Section 9
 
What limit of professional indemnity cover does the Proposer require:
   
           $1,000,000           $2,000,000            $5,000,000             $10,000,000           $20,000,000 
 

What is the Proposer's preferred claim excess (in most cases an excess is compulsory)

 
         $2,500           $5,000            $7,500             $10,000       Other
 
Does the Proposer require the insurance to include:-
     
a)   Reinstatement of Aggregrate Limit of Indemnity         Yes      No
 
 
b) Fidelity Cover    Yes      No
     
c) Partners Previous Business    Yes      No

Fidelity Cover - if the Proposer requires Fidelity Cover, please answer questions a) b) and c) below :-
     
a)   Does the Proposer always obtain references before hiring employees?    Yes      No
 
 
b) Does the Proposer require more than one staff member to sign cheques, handle cash and/or deal with transferrable documents?

   Yes      No
c) Is the Proposer's Bank Reconciliation done by someone not authorised to deposit or withdraw from the bank accounts?

   Yes      No

  If No, to a), b) or c) please give details


Partners Previous Business - if the Proposer requires this cover, please provide:  
       
Name of
Partner - Principal - Director
Name of Previous Practice Period Practicing as a Partner - Principal - Director  
 
       
 
         
   
       

 
       

 


ATTACHMENTS - FINANCIAL ACCOUNTS - CV's and RESUMES
Section 10
 
Most Underwriters will require a copy of the Proposer's last set of Annual Accounts and Resumes and/or CV's of the Directors - Partners - Principals. [as listed in Section 2 of this Proposal]. Please try to provide this information so we can present a full picture of your PI' needs to Underwriters.
 
Please attach (if possible) the last set of Annual Financial Accounts for the Business:
(Microsoft Word or PDF only)
   
YOU WILL NEED TO PROVIDE A CV' FOR EACH DIRECTOR, PARTNER, PRINCIPAL OR IF YOU ARE A SOLE TRADER - ATTACH CV's TO THIS FORM USING THE BROWSE BUTTONS BELOW
   
Please also attach Resumes of the Directors - Partners - Principals as listed in Section 2 of this Needs Analysis Form
(Microsoft Word or PDF only)

Director or Partner 1


Director or Partner 2

Director or Partner 3

Director or Partner 4

Director or Partner 5
   
PROPOSER'S DECLARATION
Section 11
 


DECLARATION

I, , being a [Partner, Principal, Director] of the Proposer, hereby declare and warrant: -
     
1)   I am authorised to complete this Proposal on behalf of the Proposer; and;
     
2)


  I have read and understand my obligations of duty of disclosure under the Insurance Contracts Act 1984 and have made enquires to ensure all answers to the questions contained in this Proposal are true and correct to the best of my knowledge and belief and that no information whatsoever has been withheld; and
     
3)   I have read and agree to the 'Terms & Conditions' relating to this Proposal, including matters concerning the 'Privacy Act' and how the information I have provided might be used; and
     
4)   I understand that the submission of this Proposal does not bind or obligate any party to enter into a binding contract of insurance.
 
I, agree to the above terms         Yes         No

Note: If insurance terms are provided to the Proposer, and the Proposer accepts the terms and wishes to proceed with the insurance cover, the Proposer may be required to physically sign a copy of the Proposal before insurance cover is provided.


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