Main Menu     Quotations    Motor Hotline    Send Email     Contact Us 

 Brokers National 

Brokers National specialises in Professional Indemnity insurance                                      For all senior staff giving advice a short Resume of qualifications, employment history, & experience is required                                                          Professional Indemnity provides protection against errors, ommisions, and / or wrong advice                                                        Simply complete the information below and send it to our office with your Resumes

EMAIL Or FAX

On-Line Professional Indemnity Insurance Quote


Thank you for considering our on-line professional indemnity insurance quote service. Brokers National has accounts with most insurers and underwriting agencies. We aim to find you the best professional indemnity insurance deal possible.

Please fill in the following form - answering all questions, then either:

1. Click on "Email to Brokers National" at the bottom of this form.  OR                               

2. Highlight this form to "Print It" and then "Fax It" to our office on 03 9791 6633.


 Use the Mouse or the Tab key to move to the next field. We will respond with quotes as soon as they have been received from our insurers.


Professional Indemnity
Full Legal Name Of Company / Business:
Other Parties To Be Insured:
Registered Office Address of Business:  

Number of years in this business?: years
Sum Insured required?: $
The excess you wish to pay towards a claim?: $
Do you currently have professional indemnity insurance? Yes    No
If yes, please provide details below:
 Current Expiry date:
Current Insurance company:
Current Indemnity limit: $ Sum Insured
Current Excess: $
Premium Payable: $


Please give a clear description of activities to be covered:

Particulars of Principal(s)- Important: Please attach short Resume for each person.

Name of Principal(s)
Qualifications
Professional Associations



 Details of gross income/fees or commissions:
Received / rendered during the last 12 months: $ Gross Income / Fees
 Estimated Income / fees for next 12 months: $ Gross Income / Fees
Are any of your operations located outside of Australia Yes   No


If the answer to either of the above is "Yes", please specify which countries and percentage of income deriving from each :
Have you ever had a liability insurer:    
(a) Decline a proposal ? Yes   No
(b) Impose special terms ? Yes   No
(c) Decline to renew your insurance ? Yes     No
(d) Cancel your insurance ? Yes     No

 

If the answer to either of the above is "Yes", please provide details below. ...............

. ..........................

Have any claims ever been made against you, or your firm  in business individually or otherwise, in respect of this class of insurance? Yes    No
Are any of the Partners/Principals/Staff, aware of any facts or circumstances which are likely to give rise to a claim against the Firm or any of the present or former Partners/Principals? Yes    No
Has any principal or staff member been subject to Disciplinary Proceedings for professional misconduct ? Yes    No


If the answer to either of the above is "Yes", please provide details below.
Under the Insurance Contracts Act, you have a Duty of Disclosure. Is there any matter not disclosed above or in the attachments that is relevant to the acceptance of this proposal? Yes    No


If so, please provide details below.
 
Please advise the total number of:    

(a) Qualified staff-including Principals
(please specify professional discipline)

  
(b) Other technical staff  
(c) Non-technical staff (including typists, receptionists etc.)  
Total of all staff  
Are you or have you or any company, subsidiary or other related entity either: (i) engaged in, or; (ii) have or had a controlling share of an entity involved in;
   

(a) Construction, fabrication, erection or contracting ?

   Yes    No

(b) Real estate development ?

   Yes    No

(c) The manufacture, sale or distribution of any product or process or patented production process ?

   Yes    No

 

If the answer to either of the above is "Yes", please provide details below.

 

Names of the other entities involved, outlining their relationship to you?

 

Full details, including a description of the nature of the involvement.

 

Contacting you about your quote:

Please make sure you leave a contact phone number and the best time to call you.
Your Name:
Company name:
Your Phone Number & Area Code:
Best Time(s) To Call:
Please send my quote by (select at least one): email     phone     fax     mail
Your Email:
Your Facsimile:
Your Postal Address:

Click On Email Quote To Send         Form To Us
 

Main Menu     Quotations    Motor Hotline    Send Email     Contact Us