Professional Indemnity Insurance Quote

Complete the following form, and our team will respond to you within 1 working day.

Name *
Name
Phone Number *
Phone Number
Insured Details
Full names of all entities requiring cover including trading names
Business Commencement Date *
Business Commencement Date
Business Address *
Business Address
http://
Period and Limits of Insurance
Insurance cover to commence *
Insurance cover to commence
Insurance cover to cease *
Insurance cover to cease
$
Do you require any of the following extensions?
Select all that are applicable
Business Particulars
Fees
Please give the total annual gross fees for advice given in each of the last two financial years and an estimate for the current 12 months
$
$
$
$
$
$
Qualifications
Include full name, qualifications, date qualification was obtained, and how long they have been a partner/director/principal
Subcontractors
Do you use subcontractors? *
$
$
Do you always check the insurance of subcontractors?
Other Information
Does the firm enter into any written agreements or letter of appointment? *
If 'Yes', please forward example to admin@doringinsurance.com.au
Does the firm issue any literature, etc, describing the services? *
If 'Yes', please forward example to admin@doringinsurance.com.au
Include title of contract and the fee
Include title of contract and the fee
Do you require this insurance to provide for legal actions bought? *
Business Operations Outside Australia
Do you operate outside Australia? *
Include location, operations, and annual gross fees
USA and Canada
Please email copies of all contracts in relation to the USA or Canada to admin@doringinsurance.com.au
Have you given Power of Attorney to any person or corporation in the USA or Canada? *
Do you have any assets/company located in the USA or Canada? *
Do you have any employees or other representatives in the USA or Canada? *
Claims and Insurance History
$
$
If you currently have insurance, what is the date of expiry?
If you currently have insurance, what is the date of expiry?
Has any claim for professional negligence, error or omission ever been made against the firm and or partners/directors/principals or employees and or their predecessors in the firm, whether insured or not? *
Include date, particulars, cost, and name of insurer (if any)
Are any of the partners/directors/principals or employees AFTER ENQUIRY aware of any circumstances which are likely to give rise to a claim against the firm or its predecessors in business or any of its present or former partners/directors/principals or employees? *
Include date, particulars, cost, and name of insurer (if any)
Declaration
Declaration for and on behalf of Named Insured *
I/We declare and warrant that after enquiry all statements and particulars contained in this proposal and addenda are true and that no information whatever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this proposal and should the above particulars alter in any way I/We will advise the Underwriters as soon as practicable. I/We understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of the proposal may result in the Underwriters refusing to provide indemnity or voiding the policy in every respect.