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ARCHITECTS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

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ARCHITECTS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM Powered By Docstoc
					                                                       APUA
                                                       Suite 101, 16 Hunter Street
                                                       Hornsby NSW 2077
                                                       Phone: 61 02 9477 4779
                                                       Fax:    61 02 9477 4778




                                                         ARCHITECTS

                                 PROFESSIONAL INDEMNITY INSURANCE

                                                     PROPOSAL FORM

What is a proposal?
This proposal tells the insurers information, which the insurers need to know in order to decide
whether to offer you insurance, the premium to be charged, any deductibles to apply to any claim and
whether any special conditions should be imposed on the policy.

How to complete this proposal

1. Before completing this proposal, you should read the important notices below (in particular the duty of
   disclosure notice).
2. Before completing this proposal, you should ask each entity or person to be insured under this insurance
   about the questions and declarations to be completed on their behalf.

3. Where provided, please tick the box that indicates your response. Answer each question in the proposal fully,
   accurately and clearly. Where there is insufficient space to answer a question please answer on an attached
   separate sheet.
Please keep a copy of the completed proposal for your records.

Your duty of disclosure (applicable to each person or entity being insured)
Before the insurers agree to give you insurance, you must tell the insurers every matter that:
•   you know; or
•   could reasonably be expected to know
which is relevant to the decision to give you insurance and the terms on which it is provided.

You have the same duty to disclose those matters to the insurers before you renew, extend, vary or reinstate
your policy.

You do not need to tell the insurers anything that:
•   reduces the insurers risk;
•   is commonly known;
•   the insurers already know or ought to know in the ordinary course of business as insurers; and
•   the insurers tell you they don’t wish to know

If in doubt it is better to tell the insurers because if you do not comply with your duty of disclosure, the insurers
may:
•    refuse or reduce a claim;
•    cancel your policy; or
•    if your failure is fraudulent, avoid your policy from its beginning.




V7491 01/05/09 A                                                                                                                 Page 1 of 8

Vero Profin is a division of Vero Insurance Limited ABN 48 005 297 807 • APUA is a trading name of Vero Insurance Limited ABN 48 005 297 807
Please note – Your duty is not limited to answering the specific questions in this proposal. You must
also tell the insurers about any other relevant matters.
Your duty also requires you to tell the insurers of changes to any matters disclosed in this proposal
which occur after the proposal is submitted but prior to cover being entered into.

What is a claims made policy?

The insurance you are applying for is a ‘claims made’ policy, which covers claims made during the
period of cover. It does not provide cover for:
•      claims arising from an event which occurred before the policy’s retroactive date specified in the schedule;
•      claims made after the period of cover expires (even where the event giving rise to the claim occurred during
       the period of cover);
•      claims made before the commencement of the policy;
•      claims arising from facts or circumstances of which you first became aware before commencement of the
       policy and which you knew or ought reasonably to have known, had the potential to give rise to a claim under
       the policy or under any previous policy; and
•      claims arising from circumstances noted on the proposal form or any previous proposal form for this
       insurance.

However, where you give the insurers written notice of facts that might give rise to a claim under the policy as
soon as was reasonably practicable after you became aware of them and before expiry of the period of cover, the
policy will, subject to its terms and conditions, cover you for any claim made after the expiry of the policy period
of cover which arises from those facts.

The above is subject to the terms and conditions of the policy wording which you should read carefully.

What happens where you waive your right to recover loss from another person?

If another person would be liable to compensate you for any loss covered by the policy, but you agreed with that
person either before or after the loss occurred, not to make a recovery against them in relation to such loss, you
will not be covered under the policy to the extent you have waived your rights to recover that loss from them.
Question 4.2 (b) asks you about such agreements.


Average provision

If a payment in excess of the limit of indemnity under the policy needs to be made to finalise a claim, the
insurer's liability for defence costs incurred, with its written consent, will be the same proportion of the defence
costs as the amount of the limit of indemnity bears to the amount of your civil liability, in respect of the claim.




    V7491 01/05/09 A                                                                                                             Page 2 of 8

Vero Profin is a division of Vero Insurance Limited ABN 48 005 297 807 • APUA is a trading name of Vero Insurance Limited ABN 48 005 297 807
1.     APPLICANT DETAILS
     1.1
     Names of current practice(s)
                                                                   ABN Number                       Date Established
     to be insured




     1.2     Date Business Established

     1.3     Registered Address



             Phone: ( )                                                           Fax: ( )
             Email:                                                               Website:

     1.4     Branches

     Australia                                                           Overseas




     1.5     Employees
             (a) Total architects employed including principals
             (b) Total other professional staff
             (c) Other staff (total)
             (d) Total of all staff

     1.6     Principals/Partners/Directors
             Please provide the following details of your current principals, partners and/or directors.
             The identification of previous practices in which you were a principal, partner and/or director is essential
             to ensure automatic cover for your liability arising out of such previous practices.

                                                                     Years practising as principal
     Names of principals,                                                                                 Names of previous
                                    Age       Qualifications         This Practice      Previous
     partners or directors                                                                                unrelated practices
                                                                                        Practice




     1.7     Are you registered for GST?          Yes           No                ABN Number
             To what extent are you entitled to claim an Input Tax Credit on your insurance premiums?                                     %


2.    EXISTING OR PAST INSURANCE COVER
     2.1     Is the practice at present insured for Professional Indemnity risks?                                      Yes           No



     V7491 01/05/09 A                                                                                                                 Page 3 of 8

     Vero Profin is a division of Vero Insurance Limited ABN 48 005 297 807 • APUA is a trading name of Vero Insurance Limited ABN 48 005 297 807
     2.2     Please provide full details of any professional indemnity insurance held by the Applicant during the past
             three years

     Insurer(s)                               Expiry               Sum Insured              Deductible                Premium




     2.3      In respect of the Practice of any principal, have any Professional Indemnity Insurers
              (a) Declined a proposal?                                                                                 Yes           No
              (b) Imposed special terms?                                                                               Yes           No
              (c) Declined to continue your insurance?                                                                 Yes           No
              (d) Cancelled your insurance?                                                                            Yes           No
              Please provide details of any questions answered in the affirmative (use separate sheet if necessary).


3.    CLAIMS HISTORY
     3.1      Has the Applicant or any of its principals, partners, directors or staff members,
              or any of the Applicant's predecessors, or any prior practice of any of its present
              or former partners, principal, or directors ever been subject to disciplinary
              proceedings or actions for misconduct in a professional respect?                                         Yes           No

              If Yes, please provide details

     3.2      Has the Applicant or any of its principals, partners, directors or staff members, or
              any of the Applicant's predecessors, or any prior practice of any of its present or
              former partners, principals, or directors:
              (a) ever been subject to any claims for civil liability or breach of professional duty
                  in the last ten (10) years?                                                                          Yes           No
              (b) ever notified circumstances to insurers that may give rise to such a claim?                          Yes           No
              If Yes to either part (a) or (b) please provide the following details in respect to
              each matter. (Use separate sheet if necessary)

     Date Matter
                              Name of Insurer (if any)               Name of Claimant or Potential Claimant
     Notified




                                                                     Amount paid or Estimated           Is the matter Finalised or
     Brief Description of Matter
                                                                     Potential Liability                Outstanding?




     V7491 01/05/09 A                                                                                                                 Page 4 of 8

     Vero Profin is a division of Vero Insurance Limited ABN 48 005 297 807 • APUA is a trading name of Vero Insurance Limited ABN 48 005 297 807
     3.3        Is the Applicant or any of its principals, partners or directors aware after
                reasonable enquiry of all staff and managers, of any other facts or
                circumstances which may give rise to a claim of the type insured by the
                proposed insurance?                                                                                    Yes           No
                If Yes, please provide details:

     Name of Claimant/ Potential
                                            Brief Description of Matter                                       Estimate of Liability $
     Claimant




4.    DETAILS OF BUSINESS
     4.1        Please express as a percentage of your gross professional fees your revenue as a specialist consultant in
                the following activities:

                                                                                               (B)
                                               (A)
                                                                                               Of these professional services, what
                                               For professional services which are
                                                                                               % of (A) do you let to outside
                                               the responsibility of your practice
                                                                                               consultants?
     Architecture                                                                       %                                                 %
     Interior Design                                                                    %                                                 %

     Drafting                                                                           %                                                 %
     Landscape Architecture                                                             %                                                 %
     Town Planning                                                                      %                                                 %

     Structural Engineering                                                             %                                                 %
     Mechanical Engineering                                                             %                                                 %
     Electrical Engineering                                                             %                                                 %

     Civil Engineering                                                                  %                                                 %
     Surveying -
        I   Land                               I                                         %     I                                          %
        II Quantity                            II                                        %     II                                         %
        III Building                           III                                       %     III                                        %
     Construction Management                                                            %                                                 %
     Project Management                                                                 %                                                 %
     Other Activities
                                                                                        %                                                 %
     (Please specify)


     4.2        Does the Applicant engage consultants, sub-contractors or agents?                                      Yes           No
                If Yes,
                (a) Does the Applicant insist they carry their own Professional
                    Indemnity Insurance?                                                                               Yes           No

                (b) Does the Applicant enter into any hold-harmless agreements or otherwise
                    waive any legal rights or entitlements which it may have against such
                    consultants, sub-contractors or agents?                                                            Yes           No



     V7491 01/05/09 A                                                                                                                 Page 5 of 8

     Vero Profin is a division of Vero Insurance Limited ABN 48 005 297 807 • APUA is a trading name of Vero Insurance Limited ABN 48 005 297 807
4.3     Please state as a percentage of your gross professional fees in the last year, the type of work falling in
        the following categories:

a) Domestic Premises (not being flats or townhouses)                                                                               %
b) Commercial Premises (including retail shops flats and townhouses but excluding
                                                                                                                                   %
   work defined in d) and e))
c) Institutional Premises (such as ecclesiastical, health, municipal, educational and
                                                                                                                                   %
   recreational but excluding high rise - see e) below)
d) Industrial Premises (excluding high rise - see e) below)                                                                        %
e) High Rise Premises of all classes a) to d) inclusive exceeding three floors                                                     %
f) Town Planning                                                                                                                   %
g) Modular Buildings involving repetitive design                                                                                   %
h) Landscape Architecture                                                                                                          %
Other activities eg dams, bridges, soil testing etc. Please specify with appropriate percentages
                                                                                                                                   %
                                                                                                                                   %
                                                                                                                                   %
                                                                                                                                   %
Total                                                                                                                         100%

4.4     Please give a brief description, contract value and fees of the four largest contracts undertaken during
        the last five years:

Brief Description                                           Location




Professional Role
                                                            Contract Value                           Fees
 ie Architect, Project Manager, etc.




4.5     Has the practice undertaken work where the professional liability arising therefrom
        has been or is protected by a Specific Project Insurance Policy?                                          Yes           No

        (a) Name of the Project
        (b) The date of the practical or expected practical completion
        (c) Sum Insured provided under that policy
        (d) The approximate contract value of the project works



 V7491 01/05/09 A                                                                                                                 Page 6 of 8

 Vero Profin is a division of Vero Insurance Limited ABN 48 005 297 807 • APUA is a trading name of Vero Insurance Limited ABN 48 005 297 807
5.    BUSINESS INCOME
     5.1      Please provide date of your financial year end:
     5.2      Please provide the amount of gross income/fees for:
                                                                            Australia $A                      Overseas $A
     (a) current financial year (estimate)
     (b) last financial year
     (c) previous financial year


     5.3      Please provide details of work performed outside Australia and work for overseas clients:




     5.4      Please provide the approximate percentage of your activities (based on fee income) applicable to each
              State, Territory and Overseas:

       NSW              VIC           QLD              SA             WA             TAS             NT             ACT            O/S
              %               %             %               %              %               %              %               %               %

6.    COVER REQUESTED
     6.1      What sum insured do you require?                                              $
     6.2      What deductible do you require? (Minimum $2,000)                              $
     6.3      Retroactive Liability extends the policy to provide cover for Liability
              arising from work carried out prior to the inception of the policy to
              which this proposal relates where there is no reason to believe
              circumstances exist which could give rise to a claim.
              Do you require Retroactive Liability Cover?                                                              Yes           No

              If Yes, specify date from which Cover required                                                                   /     /

     6.4      Has the insured Practice(s) (including previously incorporated practices
              now included in this practice) had continuous Professional Indemnity
              Insurance from the date specified above?                                                                 Yes           No

     6.5      Preferred inception date of your policy                                                                          /     /


     The Privacy Act 1988 requires us to inform you that:

     Purpose of collection
     We collect personal information (this is information or an opinion about an individual whose identity is apparent
     or can reasonably be ascertained and which relates to a natural living person) for the purposes of: providing
     insurance services to you, including to evaluate your application, to evaluate any request for a change to any
     insurance provided; to provide, administer and manage the insurance services following acceptance of an appli-
     cation; to investigate and, if covered, manage claims made in relation to any insurance you have with us or
     other companies within the same group.
     The personal information collected can be used or disclosed by us for a secondary purpose related to those
     purposes listed above, but only if you would reasonably expect us to use or disclose the information for this
     secondary purpose. However for sensitive information, the secondary purpose must be directly related to one or
     more of the purposes listed above.



     V7491 01/05/09 A                                                                                                                 Page 7 of 8

     Vero Profin is a division of Vero Insurance Limited ABN 48 005 297 807 • APUA is a trading name of Vero Insurance Limited ABN 48 005 297 807
Disclosure
We may disclose your personal information (and receive some personal information from), when necessary and
in connection with the purposes listed above, to other companies within the same group, your insurance broker
or our agent, Government bodies, loss assessors, claim investigators, reinsurers, other insurance companies,
mailing houses, claims reference providers, other service providers, hospitals, medical and health professionals,
legal and other professional advisers.

Consequences if information is not provided
If you do not provide us with the information we need we will be unable to consider your application for
insurance cover.

Access
You can request access to the personal information by contacting a Vero office at the address shown on the
last page of this Proposal Form.

Privacy Statement issued: Vero Insurance Limited, 465 Victoria Avenue, Chatswood, NSW 2067.


DECLARATION

•   I/We have made due enquiry of the Applicant and its principals, partners, directors and employees concerning
    the questions asked within this proposal and have authority to sign this proposal on their behalf;
•   I/We have read and understood the Important Information of this Proposal;
•   The statements and particulars in this proposal are true and correct;
•   This proposal along with any other information supplied by me/us shall form the basis of any policy entered
    into;
•   I/We understand that up until the policy is entered into, we must notify any change in the matters disclosed
    in this proposal; and
•   I/We will notify any material alteration to the matters disclosed in this proposal occurring after completion of
    the proposal.


Name of Applicant:

Signed by or on behalf of the Applicant                                                                    Date:       /       /

Signed by: Partner, Principal or Director                                                                  Date:       /      /

                   Signature of this form does not bind you or the insurer to complete the insurance




V7491 01/05/09 A                                                                                                                   Page 8 of 8

Vero Profin is a division of Vero Insurance Limited ABN 48 005 297 807 • APUA is a trading name of Vero Insurance Limited ABN 48 005 297 807

				
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Description: ARCHITECTS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM