Important notices to applicants

Claims Made

Professional Indemnity Insurance is ‘claims made’ insurance. This means there must be a valid
policy in place at the time you first become aware of, and notify a claim to your insurer, regardless
of whether the claim relates to activities performed in a previous policy period. If you are aware of
any claim against you, or of any facts or circumstances that may give rise to a claim against you, it
is imperative that your current insurer receives written notification of the claim or circumstances
before the expiry date noted above.
Your Duty of Disclosure

Your duty of disclosure

Before you enter into an insurance contract, you have a duty to tell us anything that you know, or
could reasonably be expected to know, may affect our decision to insure you and on what terms.
You have this duty until we agree to insure you.
You have the same duty before you renew, extend, vary or reinstate an insurance contract.
You do not need to tell us anything that:
• reduces the risk we insure you for; or
• is common knowledge; or
• we know or should know as an insurer; or
• we waive your duty to tell us about.
If you do not tell us something
If you do not tell us anything you are required to, we may cancel your contract or reduce the
amount we will pay you if you make a claim, or both.
If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it
never existed.
It is therefore vital that you enquire of all principals and senior staff before you complete your
proposal form, and before you sign any declaration that there has been no change in the
information disclosed.
Agent of the Insurer

Please note that in arranging the contract of insurance, we are acting under an authority given to
us by the insurer, and we will be effecting the contract of insurance as agent of the insurer, and not
as your agent.
Retroactive Liability

The insurance does not provide cover in relation to acts, errors or omissions that occurred prior to
the commencement of this insurance unless the policy is extended accordingly.

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 Small Practices Facility

PROFESSIONAL INDEMNITY INSURANCE

REPLACEMENT POLICY DECLARATION

1. List the full legal name of all entities to be insured

2. Principal/Partner/Director details
Name(s) Age Qualifications Registered Years practising as Principal/Director
Practitioner Yes/No This Practice Previous Practice

3. Your gross professional fees (excluding GST) Australia Overseas

Earned for the last 12 months $ $
Anticipated for the next 12 months $ $
If any overseas fees are declared please list the countries:

4. Please detail the percentage breakdown of this fee income

ACT NSW Vic QLD SA WA Tas NT Overseas

5. Total number of employees

Principals Employees

6. Has there been any change in your practice in the past 12 months?
Yes No If yes, please provide details

7. Do you envisage any substantial changes in your activities or are there any new operations contemplated
during the next 12 months?
Yes No If yes, please provide details

8. Have any claims been made, or have there been any circumstances that may give rise to a claim, that have
not been reported to Planned Cover?
Yes No If yes, please provide details

9. Has the insured entity ever worked on a project that exceeded $500 million in value?
Yes No If yes, please provide details

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 10. Express as a percentage your gross fee earnings in the following activities:
Architecture (incl contract administration) % Fashion/Textile Design %
Interior Design % TV/Film/Theatre/Set Design %
Landscape Architecture % Exhibition/Display Design %
Town Planning % Industrial Design %
Energy Rater % Teaching/Lecturing/Education %
Drafting / Building Design % Engineer - Civil %
Heritage Consultant % Engineer – Mechanical / Electrical %
Environmental Consultant % Engineer – Fire Protection %
Furniture/Product Design % Quantity Surveyor %
Jewellery Design % Land Surveyor %
Graphic Design % Project/Construction Manager %
Web/Multi Media/Digital Media Design % Other (Specify) %
Visual Communication Design % Total must equal 100%

11. Express as a percentage your work in the following areas:

Domestic Buildings % Interior Design %
Commercial/Industrial Buildings % Landscape Architecture %
High Rise Buildings over 5 storeys % Bridges/Tunnels %
Commercial Tenancy Fitout % Product Design %
Domestic Surveying % Other (Specify) %
Commercial Surveying % Other (Specify) %
Town Planning % Total must equal 100%

13. Do you require advice on or a quotation for other commercial and/or life insurance?
Public and Products Liability, Property/Office or other commercial insurances Yes No
Life, TPD or Income Protection Insurance Yes No
If yes specialists in these types of insurance from our Company will contact you

Small Practices Facility

Our Small Practices Facility is designed to cater for the needs of small design practices and construction industry
related practices. If your practice has grown or changed over the past 12 months you may no longer fit within
the guidelines of this facility. If this is the case we will contact you and advise you. We will also attempt to obtain
quotation terms from other suitable markets for you to consider. To do this we may require additional information
from you.
Declaration
I/We hereby declare that:
• I/We have read and understood the important notices at the beginning of this proposal form.
• The undersigned are authorised to act for and on behalf of all persons who may be entitled to
indemnity under any policy which may be issued pursuant to this proposal and that I/we
complete this proposal on their behalf.

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 • The above statements are true, that I/we have not suppressed or mis-stated any facts, and
that should any of the information given by me/us alter between the date of this proposal and
the inception date of the insurance to which this proposal relates I/we will give immediate
notice thereof.
Enquiry should be made of all principals/partners/directors and senior staff to ensure full disclosure.
The proposal should be signed by the principals/partners/directors. Signing the form does not bind
the practice to accept the insurance or the insurers to provide a quotation.

Name Signed Title Date

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