Quadrant PI Insurance Application Form

2024 APPLICATION & DECLARATION FOR PROFESSIONAL INDEMNITY INSURANCE

Please complete this form online and submit electronically or print sign date, scan and return to: philm@hutchrod.co.nz please note this cover is only available via Quadrant PI Ltd
Your Name*

First NameLast Name
Insured Name (FAP)
Name of company
Phone Number*

Area CodePhone Number
Email*
example@example.com
FAP No*
Please show FAP No or if working under another FAP licence please name the holder of the FAP
Is your PI insured with any of the following

QBENZFSG (Aon)TAP (Aon)None (new business)None (Expired PI)Other
Current renewal date of current PI

DayMonthYear
Please Advide Data of Current Coverage Expiry
Are you a member of any of the following, please show details if Other?*

mySolutionsTriple AFANZOther
Number of advisors*
Please advise how many advisors you have
Number of Admin Support staff*
Please advise total number of staff excluding advisors
Do you require cover for Consultants, Contractors or External Agents? *
If yes please advise details, Business name, Adviser name, FSP No
Gross income Last Financial Year $*
Gross income Estimated next financial year $*
Please detail business activity & income split in dollar amount (If nil please show 0)*
Do you provide advice or have clients based overseas? If so please advise total revenue from these clients. Note cover is provided for NZ domiciled advisers advising NZ citizens who are based overseas (excluding USA/Canada).
**Additional information required for DIMS

Please email separately the following

Please provide total funds under management; what are the procedures for confirming alterations back to client’s; split between unitised funds and shares; other direct investments (please specify)
***Additional Information required if Fire & General Revenue exceeds 10% *
Please advise - Type of business transacted (Commercial or Domestic) Insurer's with whom you hold Direct Agencies; Broker details if referral to F&G Broker (eg Stylecover). Details of any F&G qualifications or experience
Your Duty of Disclosure

Before you enter into this insurance you have a duty, at law, to disclose to us all material facts.This duty also applies when you renew, vary, extend or reinstate your policy.

A material fact is one that may influence a prudent insurer in deciding whether or not to accept the insurance and, if so, on what terms and conditions and for what premium.

Please read the duty of disclosure below and advise of any material facts (eg claims, convictions) need to be declared insert below:

Examples of information you may need to disclose include but are not limited to:

Anything that increases the risk of an insurance claim.

Subject to the Criminal Records (Clean Slate) Act 2004, any criminal conviction or offence.

If another insurer has cancelled or refused to insure or renew insurance, has imposed special terms, or refused any claim.

Any insurance claim made or loss suffered in the past.

These examples are a guide only. If there is any doubt as to whether a particular piece of information needs to be disclosed, this should be referred to Hutchison Rodway.

If you fail to comply with the Duty of Disclosure, it may result in your claim being declined, the amount we pay if you make a claim being reduced or the contract being void from inception.
Please detail any claims or other material facts below*
Declaration

On behalf of all proposed Policyholders I/We declare and agree that:

a. all information provided, in this renewal declaration or attachments, is true and complete in every respect and that no Material Facts remain undisclosed;

b. if this risk is accepted, such information will be incorporated into and form the basis of the contract of insurance;

c. I/We understand that the Insurer requires this information in order to evaluate this proposal and that the Privacy Act 2020 entitles me/us to have access to, and request the correction of, any information retained;

d. Hutchison Rodway Ltd & Quadrant PI Ltd are authorised to disclose information to the Insurer, reinsurers, other insurers and parties with a financial interest in the subject matter of this proposal;

e. The Insurer is authorised to check details against the Insurance Claims Register and to place information on the Insurance Claims Register which other insurers can access;

f. Hutchison Rodway Ltd on behalf of Quadrant PI Ltd and the Insurer are authorised to obtain from other parties any information which may be relevant to the acceptance of this risk;

g. the signing of this declaration does not bind either party to complete the contract and that no cover will be in force until confirmed by Quadrant PI Ltd, their nominated Insurance Broker and the Insurer.
I/We confirm that I/We have read the Duty of Disclosure and Declaration above and agree that by entering my name and clicking "Submit" I/We am electronically signing this Application. I /We confirm the appointment of Hutchison Rodway Ltd as our Insurance Brokers for PI and Liability insurance.*

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Date*

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2024 APPLICATION & DECLARATION FOR PROFESSIONAL INDEMNITY INSURANCE