Engineers & Surveyors Proposal Form "*" indicates required fields 1Your Details2Your Business3Your Risk Management Program4Your Financial Details5Your Claims History6Your Insurance History7Your Insurance Request PhoneThis field is for validation purposes and should be left unchanged.Please complete all questions fully. If there is insufficient space provided to answer please provide details on your letterhead.Please provide the full legal name of all entities to be insured under the Policy*(It is important you include all service, administration or nominee companies)Trading Name*Your ABNDate Established:* DD slash MM slash YYYY Your Contact DetailsAddress:*Telephone Number:Email:* Website: Address of any Branch Offices:Principals/Partners/Directors:NameQualificationDate ObtainedYears as a Principal (This Practice)Years as a Principal (Previous Practice) Add RemoveStaff DetailsPrincipals/Partners/Directors:Qualified Staff:Other Technical Staff:Administrative Staff:Other Staff:Total Staff:Are you a current financial member in good standing of a Professional Association?* Yes No If yes, please provide details of the Associations to which you belong:* Has the name of your business ever changed?* Yes No Have you ever amalgamated or merged with another business?* Yes No Have you purchased any other business or practice?* Yes No If you have answered Yes to any of questions above, please provide full details:*Does any Principal, Partner or Director of the Insured detailed in answer to question 1.1 of this proposal have any connection or association (financially or otherwise) with any other business or practice?* Yes No If yes, please provide details:*Please provide a precise description of your business activities:*Please provide details of your five largest contracts in the last five years:*Brief Description of ContractLength of ContractTotal Value of ContractYour Income from the Contract AUD$ Add RemoveHave there been any substantial changes in your business activities in the past 12 months?* Yes No Do you anticipate any substantial changes in your business activities in the next 12 months?* Yes No If you have answered Yes to any of questions above, please provide full details:*Do you engage sub-contractors?* Yes No If yes, do you insist they carry their own Professional Indemnity Insurance?* Yes No Are verbal reports always confirmed in writing?* Yes No If no, please advise how these reports are substantiated*Do you perform work outside of Australia, or work for clients located overseas?* Yes No If yes, please provide details:*For Sole Proprietors ONLY (otherwise please proceed to the next section)Please provide details of the length of service & experience of your assistants:Please provide details of the arrangements you have in place to assist you during temporary absences?Are you, or any subsidiary company, involved in any actual construction, erection or fabrication?* Yes No Are you, or any subsidiary company, involved in manufacturing, sale or distribution of any product?* Yes No If you have answered Yes to either questions above please provide full details:*Have you had, do you have, or do you intend to have any past, present or future involvement on any project that involves aluminum composite panels / non-compliant cladding systems?* Yes No Do you have, had, or intend to have any involvement on high rise (3 and above floors) residential and/or commercial buildings projects?* Yes No If you have answered Yes to either questions above please provide full details:*Please state the percentage of your total income derived from:ArchitectureAcoustic EngineeringCivil EngineeringChemical EngineeringElectrical EngineeringEnvironmental EngineeringEnvironmental Appraisals/ImpactEnvironmental AuditsGeotechnical/Soil EngineeringHydraulic EngineeringMechanical EngineeringStructural EngineeringMarine EngineeringMining Engineering(i) Aboveground %(ii) Underground %Surveying(i) Building – Certification including mandatory and staged inspections(ii) Building – Pest/Termite/Timber(iii) Building – Pre-purchase building inspection(iv) Building – Swimming pool/safety barrier inspection(v) Land(vi) Marine(vii) QuantityProject ManagementConstruction ManagementDraftingInterior DesignTown PlanningOther (Please provide details)TOTAL 100%Please state the percentage of your total income derived from Acoustics & Noise PreventionAirports – “Non-Airside” Terminal Buildings & InfrastructureAirports – “Airside” Tarmacs, Aprons, etcBridges - pedestrian overheadBridges precast concrete constructed in cantileverBridges prefabricated steel or precast concrete stayed by cablesBridges prefabricated steel or precast concrete suspended by cablesBridges prefabricated steel or precast concrete using non-standard beamsIndividual Dwellings -ResidentialLow rise residential/commercial (up to 3 stories) – new constructionLow rise residential / commercial (up to 3 stories) – Internal renovation or Fit outHigh rise residential/commercial (above 3 stories) – new constructionHigh rise residential / commercial (above 3 stories) – Internal renovation or Fit outSchools, Hospitals, Municipal Buildings & Recreation CentersIndustrial – Manufacturing, Warehouse & processing up to $1,000,000 in valueIndustrial – Manufacturing, Warehouse & processing above $1,000,000 In valueSecurity or Control EngineeringPetrochemicals, refineries, chemicals fertilisersMechanical Plant & Bulk Handling EquipmentDams – agricultural/irrigation purposesDams – any other purposePollution Control equipmentHarbours & JettiesMine process control equipment & systemsModular buildings - repetitive designOil & Gas PipelinesRailwaysRoadsRail & Road Tunnels up to 20 meters in lengthSewerage or Water SystemsRail & Road Tunnels over 20 meters in lengthStructures at fairs, shows & exhibitionsSilos – up to 20 meters in heightSilos – above 20 meters in heightWaste Disposal, Treatment ManagementDesign of Pollution Controls EquipmentUnderground Storage FacilitiesOther (Please provide details)TOTAL: 100% Do you have a documented Risk Management program?* Yes No If yes, when was the program implemented?*Does your Risk Management program include regular internal or external audits or reviews?* Yes No Is the program communicated to and available to all staff?* Yes No Do you use a standard form of contract or terms of engagement?* Yes No If yes, please provide a copy of your standard contract.*I will send via email separately* Yes No Upload your contact here Drop files here or Select files Max. file size: 128 MB. Do you have in place any formal procedures for the identification and reporting of incidents or circumstances which may give rise to a professional indemnity claim?* Yes No If yes,a) Provide details of these procedures:*b) Advise when they were first implemented:*Do you have formal procedures in place to review their methods, processes and practices with the intention of avoiding the future occurrence of any similar incidents or circumstances which may give rise to a professional indemnity claim?* Yes No If Yes, please provide details:* Please advise the total annual turnover and gross professional fees for:Previous 12 months Turnover $*Previous 12 months Professional Fees $Current 12 months Turnover $*Current 12 months Professional Fees $Estimate for next 12 months Turnover $*Estimate for next 12 months Professional Fees $Please provide the approximate percentage of your activities (based on fee income) applicable to each State or Territory:*NSW %VIC %QLD %SA %NT %WA %ACT %TAS %O / S %Total %Please note that total should be 100%The two following questions are ONLY to be answered if you generate income in NSWAre you a Capital Gains Tax small business entity (within the meaning of section 152-10(1AA) of the Income Tax Assessment Act 1997 (Cth)? Yes No Are you a small business individual, partnership, company and/or trust which is carrying on a business, and the business has an aggregated turnover of less than $2,000,000? (Aggregated turnover is your Australia wide annual turnover plus the annual turnovers of any business entities that are your affiliates or are connected with you). Yes No After enquiry, have any claims for negligence or breach of professional duty been made against your business or practice or any of its predecessors in business or any prior business or practice or any of its present or former Principals, Partners or Directors or has any fact or circumstance been notified to the insurers that has the potential to give rise to such a claim?* Yes No If yes, please provide full details:*Date NotifiedName of ClaimantBrief Description of MatterQuantumStatus Add RemoveAfter enquiry, are any of the Principals, Partners or Directors aware of any fact or circumstance which has the potential to give rise to a claim against your business or practice or any business or practice of any of their present or former Principals, Partners or Directors which is not referred to in Question 5.1 above?* Yes No If yes, please provide full details:*Date first became aware of matterName of potential ClaimantBrief Description of MatterQuantum Add RemoveHas any Principal, Partner or Director or staff member ever been subject to disciplinary proceedings for professional misconduct?* Yes No If yes, please provide details:*After enquiry, are any Principals, Partners or Directors or staff members aware of any enquiry, professional disciplinary proceedings or similar process connected to your business which they, or any other member may be required to attend?* Yes No If yes, please provide details:* Do you currently hold any Professional Indemnity Insurance?* Yes No If yes, please provide the following information:*Name of InsurerExpiry DateLimit of Indemnity $Deductible $Retroactive DatePremium $ Add RemoveHas the firm, any partner, principal or director ever been refused this type of insurance, had special terms imposed, had a policy cancelled or had an application for renewal declined?* Yes No If yes, please provide details:* Limit of Indemnity Options: $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 Other If yes, please provide details:*Preferred Deductible Options: $2,000 $5,000 $10,000 7.5. If you require Partners Previous Business cover please advise:Names of Principal / Partner / DirectorName of Previous PracticePeriod Practicing as a Principal / Partner / Director Add RemoveConsent* DeclarationI/We declare and warrant that all the statements and particulars here given are true and that no information whatever has been withheld which might influence a prudent Insurer’s judgment and the acceptance of this Proposal. Should the above particulars alter in any way, I/We will advise Insurers as soon as possible. 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 Insurers refusing to provide indemnity or voiding the policy in every respect. I/We hereby agree that this Declaration shall be the basis of the contract between me/us and Insurers.Name of Proposer:*Signed on behalf of all Principals / Partners / Directors:*Dated:* DD slash MM slash YYYY Δ