Profit First Professionals

DUTY OF DISCLOSURE
Before any person/s enter into an insurance policy with us, they have a duty under the Insurance Contracts Act 1984 (Cth) to disclose to us every matter that they know, or could reasonably be expected to know, is relevant to our decision whether to accept the risk of the insurance and if so, on what terms.
They have the same duty to disclose those matters to us before they renew, extend, vary or reinstate the Policy.
The duty applies until the Policy is entered into, or where relevant, renewed, extended, varied or reinstated (Relevant Time). If anything changes between the time disclosures are made and the Relevant Time, the person/s need to tell us.
What we do not need to know; A person does not need to tell us about any matter that:
•diminishes our risk;
•is of common knowledge;
•we know or should know in our business as an insurer;
•we tell the person we do not need to know.
Who does the duty apply to?
The duty of disclosure applies in relation to everyone who is insured under the Policy.
What happens if the duty of disclosure is not complied with?
If the duty of disclosure is not complied with we may cancel the Policy and/or reduce our liability under the Policy in respect of a claim. If fraud is involved, we may treat the Policy as if it never existed and pay nothing.
UTMOST GOOD FAITH
The Policy is based on the utmost good faith requiring us and the proposer/Insured(s) (including third party beneficiaries after the Policy is entered into) to act towards each other with the utmost good faith in respect of any matter relating to the Policy. A failure to comply is a breach of the Insurance Contracts Act 1984 (Cth).

1. Full legal name of company or sole practitioner or partnership (Further referred to as ‘You/Your’ in the proposal form). It is essential that You specify the legal name of the entity entering into this contract:*

2. Trading names associated with the above-named entity (if applicable):

3. Name of any of Your subsidiaries or service companies (if applicable):

4. ABN Number:*

5. Date Your business was established:*

6. Your Principal business address:*

7. Your business website(s):

8. Has your (business) name ever been changed*

YesNo

If Yes (8), please provide further details

9. Have You ever purchased or been purchased by any other business, or amalgamated or merged with any other business?*

YesNo

If Yes (9), please provide further details

10.Employee Types*

	Number of Employees
Professional Qualified Employees
Non-Technical/ Administrative Employees
Total

11. Do You use sub-contractors or sub-consultants?*

YesNo

If Yes, please specify the activities they undertake:

12. Do You verify that all sub-contractors and sub-consultants have a current professional indemnity policy in place prior to commencing work with You?*

YesNoNot Applicable

13. Describe Business Activities where services provided for a professional fee:*

14. Any other activities:

15. Do any of your activities require you to have an Australian Financial Services Licence (AFSL)?*

YesNo

If Yes, please provide a copy of your current licence(s)

16. Activity Split: Please categorize Your business activities and indicate the percentage of work this represents of your total operations:*

	Description of the Activity or service	%
Activity
Activity
Activity
Activity
Activity
Activity

17. Please state the gross fee income received for each of the last two financial years and an estimate for the next financial year in:*

	Fees (AUD)
Prior Financial Year
Current Financial Year
Next Financial Year (Estimate)

18. Please provide the approximate percentage of Your activities (based on fee income) applicable to each State or Territory in Australia and overseas (o/s)*

	% OF AVTIVITIES
VIC
NSW
QLD
SA
WA
TAS
NT
ACT
O/SEAS

19. For any activities conducted outside of Australia, please name the countries in which the work is undertaken: (Nil if no overseas activities)*

20.Are You eligible for Small Business Exemption for Stamp Duty in New South Wales in accordance with section259B of the Duties Act 1997 (NSW)?*

YesNo

If yes (20), please complete the NSW Stamp Duty Exemption form https://form.jotform.com/BenjaminandBenjamin/IME_NSW_SD_FORM

22. Are You or any Partner/Principal/Director a member of a Professional Body or Association?*

YesNo

If yes (22), please provide details.

23.Do any individual contracts or clients represent more than 25% of Your annual fee revenue?*

YesNo

24.Do You expect any significant changes to Your activities in the next 12 months?*

YesNo

If yes (23+24), please provide details.

25. Do you have a standard contract of engagement?*

YesNo

26. Does the contract clearly state a scope of works to be undertaken by you?*

YesNo

27. Does the contract include limitations of liability to Your clients?*

YesNo

28: CLAIMS/HISTORY DETAILS - Has any Insurer ever:

28a: Declined to offer insurance to You or Your Partners, Directors, or Principals (including past Partners, Directors or Principals)?*

YesNo

28b: Cancelled or voided any insurance held by You or any Partner, Director, or Principal?*

YesNo

29: Have You, including any Partners/Directors/Principals or employees:

29a: Been the subject of any disciplinary proceedings for professional misconduct?*

YesNo

29b: Been declared bankrupt?*

YesNo

29c: Held office in a company that was trading while insolvent and/or entered administration/receivership/liquidation?*

YesNo

29d: Been convicted of a criminal offence?*

YesNo

If yes (28-29), please provide details.

30.Has any claim been made against You, including any present or former Partners, Directors, Principals, Consultants or Employees?*

YesNo

31.Are You or any Partners, Directors, Principals, Consultants or Employees, after enquiry, aware of any facts or circumstances which may give rise to a claim?*

YesNo

If yes (30-31), please provide details incl. Year of Notification, Insurer, Claimant, Nature of the claim, Amount Paid and Claim Status (Closed or Outstanding)

32. Do you currently have a Professional Indemnity Insurance Policy in place?

YesNo

If yes (32), please provide the policy limit, excess amount, current premium, expiry date and insurer

Or, Upload a copy of your current policy.

33. Please select the Limit of Professional Indemnity cover you require:*

$1,000,000 Any one Claim$2,000,000 Any one Claim$5,000,000 Any one ClaimOther

34. Please select the Limit of Public and Products Liability cover you require*

$5,000,000 Any one Claim$10,000,000 Any one Claim$20,000,000 Any one ClaimI don't require Public and Products Liability

35. Do you provide any services that involve manual labour and/or use of heavy equipment or machinery, including their supervision or direction?

YesNo

36. Do You manufacture, import, export, sell, or supply any products?

YesNo

If yes (35-36), please provide further details.

Signature - Please sign*

Name*

First NameLast Name

Email*

example@example.com

Contact Phone Number*

WorkForce Details

Description of Business Activities

PUBLIC AND PRODUCTS LIABILITY COVER