PROFESSIONAL INDEMNITY RISKS PACKAGE APPLICATION FORM

Transcription

1 Are Has Financial Potential Birth:... currently firm/ Claims that company the insured - information only. ever complete carried and.. this out answers any section Indemnity work given if overseas? you in? this want proposal this cover. are in every respect true and Birth:... all information that may be material in considering this proposal. agree that this proposal and declaration shall be the Name If Are basis no, yes, Name any has please 1. and Business: Proportion the Business: incorporated firm specify:... principals, ever.... been total.... directors, in... turnover the insured ficers, for derived contract. partners,. from.... internet I/ Indemnity directors, we undertake trading sales Insurance? / e-commerce:...% Address: Confirm the Address: firm a) 2. that... Any affiliated the.. facts... Applicant. firm/company.... to or.... circumstances... currently. group/... has.... franchise able a. policy which to meet other could not.. businesses?.. give making. debts rise..... as. positive. to..... they a claim fall representations regarding Authoritythe structural condition and / or water tightness properties for sale? Postal If yes, Postal please Address: b) If No, Any Address: please specify accounts Fax:... Fax:... If, please specify:... During authorise Human business information been relating purchased to this or any other or merger any other or management held consolidation by me/us or taken any claim place? made by me/us. Are Are you 1. you a Does member a the Applicant REINZ? have procedures in place No No to counter the Business threat Employee was was established: If yes, would please theft appreciate specify such as... If require., If, please provide us us with your membership number: duties such as funds transfer, signing cheques And investing funds. Indemnity cover required for any previous business activity If 4.1 Are yes, Detail bank 2: please Cover statements. Shareholders/ provide details Receipts Principals.. Breakdown details Estate evaluate in the no. they..... have... been with.. your... firm Have you had any claims or losses? Residential Current Indemnity Sales Limit Current Excess Current If, please provide details:. Renewal Are the firm s annual current accounts policy: prepared..... by a firm Accountants? Retroactive : Industrial Level Commercial have certain Sales Indemnity rights access cover to you and require correction for quote this (tick information. Board This includes or REI/REAA any notifications disciplinary proceedings? claims. note that if you fail to make mention any claims or potential No claims, specify if a higher limit is required If, please specify provide if a higher details:. Body firm ever Corporate been declined Secretary/Management or has any such ever been cancelled or renewal refused or should Position be made aware? If *lf other, higher *lf higher please Lim Lim specify. are are required required please please the the Limit Limit required. required. If 4.2 The Numbers: standard details:... excess is 5,000 plus GST. Name The and policy s address standard any excess Branch is 5,000 fices: plus GST. Has A higher there provide excess been number any is civil available or Administration criminal request allegations : at a. or on request (tick disciplinary. proceedings, or any Licensing Board alleging (tick. Employees law and against Contractors: the Company,... principals, Are References if it were obtained force? when engaging staff? Have If, any please personnel provide involved full details with the including firm been the name dismissed the for claimant, or as a result amounts dishonesty? paid for any.. If yes, please specify... Previous 12 months.. Estimate for the next 12 months What is the average Value Properties sold in the last 12 months..

2 Are Has Financial Potential Birth:... currently firm/ Claims that company the insured - information only. ever complete carried and.. this out answers any section Indemnity work given if overseas? you in? this want proposal this cover. are in every respect true and Birth:... all information that may be material in considering this proposal. agree that this proposal and declaration shall be the Name If Are basis no, yes, Name any has please 1. and Business: Proportion the Business: incorporated firm specify:... principals, ever.... been total.... directors, in... turnover the insured ficers, for derived contract. partners,. from.... internet I/ Indemnity directors, we undertake trading sales Insurance? / e-commerce:...% Address: Confirm the Address: firm a) 2. that... Any affiliated the.. facts... Applicant. firm/company.... to or.... circumstances... currently. group/... has.... franchise able a. policy which to meet other could not.. businesses?.. give making. debts rise..... as. positive. to..... they a claim fall representations regarding Authoritythe structural condition and / or water tightness properties for sale? Postal If yes, Postal please Address: b) If No, Any Address: please specify accounts Fax:... Fax:... If, please specify:... During authorise Human business information been relating purchased to this or any other or merger any other or management held consolidation by me/us or taken any claim place? made by me/us. Are Are you 1. you a Does member a the Applicant REINZ? have procedures in place No No to counter the Business threat Employee was was established: If yes, would please theft appreciate specify such as... If require., If, please provide us us with your membership number: duties such as funds transfer, signing cheques And investing funds. Indemnity cover required for any previous business activity If 4.1 Are yes, Detail bank 2: please Cover statements. Shareholders/ provide details Receipts Principals.. Breakdown details Estate evaluate in the no. they..... have... been with.. your... firm Have you had any claims or losses? Residential Current Indemnity Sales Limit Current Excess Current If, please provide details:. Renewal Are the firm s annual current accounts policy: prepared..... by a firm Accountants? Retroactive : Industrial Level Commercial have certain Sales Indemnity rights access cover to you and require correction for quote this (tick information. Board This includes or REI/REAA any notifications disciplinary proceedings? claims. note that if you fail to make mention any claims or potential No claims, specify if a higher limit is required If, please specify provide if a higher details:. Body firm ever Corporate been declined Secretary/Management or has any such ever been cancelled or renewal refused or should Position be made aware? *lf If other, higher *lf higher please Lim Lim specify. are are required required please please the the Limit Limit required. required. Numbers: standard details:... excess is 5,000 plus GST. Name The and policy s address standard any excess Branch is 5,000 fices: plus GST. A Has higher there provide excess been number any is civil available or Administration criminal request allegations : at a. or on request (tick disciplinary. proceedings, or any Licensing Board alleging (tick. Employees law and against Contractors: the Company,... principals, Are References if it were obtained force? when engaging staff? Have If, any please personnel provide involved full details with the including firm been the name dismissed the for claimant, or as a result amounts dishonesty? paid for any.. If yes, please specify... Previous 12 months.. Estimate for the next 12 months What is the average Value Properties sold in the last 12 months..

3 Are Has Financial Potential Birth:... currently firm/ Claims that company the insured - information only. ever complete carried and.. this out answers any section Indemnity work given if overseas? you in? this want proposal this cover. are in every respect true and Birth:... all information that may be material in considering this proposal. agree that this proposal and declaration shall be the Name If Are basis no, yes, Name any has please 1. and Business: Proportion the Business: incorporated firm specify:... principals, ever.... been total.... directors, in... turnover the insured ficers, for derived contract. partners,. from.... internet I/ Indemnity directors, we undertake trading sales Insurance? / e-commerce:...% Address: Confirm the Address: firm a) 2. that... Any affiliated the.. facts... Applicant. firm/company.... to or.... circumstances... currently. group/... has.... franchise able a. policy which to meet other could not.. businesses?.. give making. debts rise..... as. positive. to..... they a claim fall representations regarding Authoritythe structural condition and / or water tightness properties for sale? Postal If yes, Postal please Address: b) If No, Any Address: please specify accounts Fax:... Fax:... If, please specify:... During authorise Human business information been relating purchased to this or any other or merger any other or management held consolidation by me/us or taken any claim place? made by me/us. Are Are you 1. you a Does member a the Applicant REINZ? have procedures in place No No to counter the Business threat Employee was was established: If yes, would please theft appreciate specify such as... If require., If, please provide us us with your membership number: duties such as funds transfer, signing cheques And investing funds. Indemnity cover required for any previous business activity If 4.1 Are yes, Detail bank 2: please Cover statements. Shareholders/ provide details Receipts Principals.. Breakdown details Estate evaluate in the no. they..... have... been with.. your... firm Have you had any claims or losses? Residential Current Indemnity Sales Limit Current Excess Current If, please provide details:. Renewal Are the firm s annual current accounts policy: prepared..... by a firm Accountants? Retroactive : Industrial Level Commercial have certain Sales Indemnity rights access cover to you and require correction for quote this (tick information. Board This includes or REI/REAA any notifications disciplinary proceedings? claims. note that if you fail to make mention any claims or potential No claims, specify if a higher limit is required If, please specify provide if a higher details:. Body firm ever Corporate been declined Secretary/Management or has any such ever been cancelled or renewal refused or should Position be made aware? *lf If other, higher *lf higher please Lim Lim specify. are are required required please please the the Limit Limit required. required. Numbers: standard details:... excess is 5,000 plus GST. Name The and policy s address standard any excess Branch is 5,000 fices: plus GST. A Has higher there provide excess been number any is civil available or Administration criminal request allegations : at a. or on request (tick disciplinary. proceedings, or any Licensing Board alleging (tick. Employees law and against Contractors: the Company,... principals, Are References if it were obtained force? when engaging staff? Have If, any please personnel provide involved full details with the including firm been the name dismissed the for claimant, or as a result amounts dishonesty? paid for any.. If yes, please specify... Previous 12 months.. Estimate for the next 12 months What is the average Value Properties sold in the last 12 months..

4 Are Has Financial Potential Birth:... currently firm/ Claims that company the insured - information only. ever complete carried and.. this out answers any section Indemnity work given if overseas? you in? this want proposal this cover. are in every respect true and Birth:... all information that may be material in considering this proposal. agree that this proposal and declaration shall be the Name If Are basis no, yes, Name any has please 1. and Business: Proportion the Business: incorporated firm specify:... principals, ever.... been total.... directors, in... turnover the insured ficers, for derived contract. partners,. from.... internet I/ Indemnity directors, we undertake trading sales Insurance? / e-commerce:...% Address: Confirm the Address: firm a) 2. that... Any affiliated the.. facts... Applicant. firm/company.... to or.... circumstances... currently. group/... has.... franchise able a. policy which to meet other could not.. businesses?.. give making. debts rise..... as. positive. to..... they a claim fall representations regarding Authoritythe structural condition and / or water tightness properties for sale? Postal If yes, Postal please Address: b) If No, Any Address: please specify accounts Fax:... Fax:... If, please specify:... During authorise Human business information been relating purchased to this or any other or merger any other or management held consolidation by me/us or taken any claim place? made by me/us. Are Are you 1. you a Does member a the Applicant REINZ? have procedures in place No No to counter the Business threat Employee was was established: If yes, would please theft appreciate specify such as... If require., If, please provide us us with your membership number: duties such as funds transfer, signing cheques And investing funds. Indemnity cover required for any previous business activity If 4.1 Are yes, Detail bank 2: please Cover statements. Shareholders/ provide details Receipts Principals.. Breakdown details Estate evaluate in the no. they..... have... been with.. your... firm Have you had any claims or losses? Residential Current Indemnity Sales Limit Current Excess Current If, please provide details:. Renewal Are the firm s annual current accounts policy: prepared..... by a firm Accountants? Retroactive : Industrial Level Commercial have certain Sales Indemnity rights access cover to you and require correction for quote this (tick information. Board This includes or REI/REAA any notifications disciplinary proceedings? claims. note that if you fail to make mention any claims or potential No claims, specify if a higher limit is required If, please specify provide if a higher details:. Body firm ever Corporate been declined Secretary/Management or has any such ever been cancelled or renewal refused or should Position be made aware? *lf If other, higher *lf higher please Lim Lim specify. are are required required please please the the Limit Limit required. required. Numbers: standard details:... excess is 5,000 plus GST. Name The and policy s address standard any excess Branch is 5,000 fices: plus GST. A Has higher there provide excess been number any is civil available or Administration criminal request allegations : at a. or on request (tick disciplinary. proceedings, or any Licensing Board alleging (tick. Employees law and against Contractors: the Company,... principals, Are References if it were obtained force? when engaging staff? Have If, any please personnel provide involved full details with the including firm been the name dismissed the for claimant, or as a result amounts dishonesty? paid for any.. If yes, please specify... Previous 12 months.. Estimate for the next 12 months What is the average Value Properties sold in the last 12 months..

5 Are Has Financial Potential Birth:... currently firm/ Claims that company the insured - information only. ever complete carried and.. this out answers any section Indemnity work given if overseas? you in? this want proposal this cover. are in every respect true and Birth:... all information that may be material in considering this proposal. agree that this proposal and declaration shall be the Name If Are basis no, yes, Name any has please 1. and Business: Proportion the Business: incorporated firm specify:... principals, ever.... been total.... directors, in... turnover the insured ficers, for derived contract. partners,. from.... internet I/ Indemnity directors, we undertake trading sales Insurance? / e-commerce:...% Address: Confirm the Address: firm 2. a) that... Any affiliated the.. facts... Applicant. firm/company.... to or.... circumstances... currently. group/... has.... franchise able a. policy which to meet other could not.. businesses?.. give making. debts rise..... as. positive. to..... they a claim fall representations regarding Authoritythe structural condition and / or water tightness properties for sale? Postal If yes, Postal please Address: If b) No, Any Address: please specify accounts Fax:... Fax:... If, please specify:... During authorise Human business information been relating purchased to this or any other or merger any other or management held consolidation by me/us or taken any claim place? made by me/us. Are Are you 1. you a Does member a the Applicant REINZ? have procedures in place No No to counter the Business threat Employee was was established: If yes, would please theft appreciate specify such as... If require., If, please provide us us with your membership number: duties such as funds transfer, signing cheques And investing funds. Indemnity cover required for any previous business activity If 4.1 Are yes, Detail bank 2: please Cover statements. Shareholders/ provide details Receipts Principals.. Breakdown details Estate evaluate in the no. they..... have... been with.. your... firm Have you had any claims or losses? Residential Current Indemnity Sales Limit Current Excess Current If, please provide details:. Renewal Are the firm s annual current accounts policy: prepared..... by a firm Accountants? Retroactive : Industrial Level Commercial have certain Sales Indemnity rights access cover to you and require correction for quote this (tick information. Board This includes or REI/REAA any notifications disciplinary proceedings? claims. note that if you fail to make mention any claims or potential No claims, specify if a higher limit is required If, please specify provide if a higher details:. Body firm ever Corporate been declined Secretary/Management or has any such ever been cancelled or renewal refused or should Position be made aware? *lf If other, higher *lf higher please Lim Lim specify. are are required required please please the the Limit Limit required. required. Numbers: standard details:... excess is 5,000 plus GST. Name The and policy s address standard any excess Branch is 5,000 fices: plus GST. A Has higher there provide excess been number any is civil available or Administration criminal request allegations : at a. or on request (tick disciplinary. proceedings, or any Licensing Board alleging (tick. Employees law and against Contractors: the Company,... principals, Are References if it were obtained force? when engaging staff? Have If, any please personnel provide involved full details with the including firm been the name dismissed the for claimant, or as a result amounts dishonesty? paid for any.. If yes, please specify... Previous 12 months.. Estimate for the next 12 months What is the average Value Properties sold in the last 12 months..

6 Are Has Financial Potential Birth:... currently firm/ Claims that company the insured - information only. ever complete carried and.. this out answers any section Indemnity work given if overseas? you in? this want proposal this cover. are in every respect true and Birth:... all information that may be material in considering this proposal. agree that this proposal and declaration shall be the Name If Are basis no, yes, Name any has please 1. and Business: Proportion the Business: incorporated firm specify:... principals, ever.... been total.... directors, in... turnover the insured ficers, for derived contract. partners,. from.... internet I/ Indemnity directors, we undertake trading sales Insurance? / e-commerce:...% Address: Confirm the Address: firm a) 2. that... Any affiliated the.. facts... Applicant. firm/company.... to or.... circumstances... currently. group/... has.... franchise able a. policy which to meet other could not.. businesses?.. give making. debts rise..... as. positive. to..... they a claim fall representations regarding Authoritythe structural condition and / or water tightness properties for sale? Postal If yes, Postal please Address: b) If No, Any Address: please specify accounts Fax:... Fax:... If, please specify:... During authorise Human business information been relating purchased to this or any other or merger any other or management held consolidation by me/us or taken any claim place? made by me/us. Are Are you 1. you a Does member a the Applicant REINZ? have procedures in place No No to counter the Business threat Employee was was established: If yes, would please theft appreciate specify such as... If require., If, please provide us us with your membership number: duties such as funds transfer, signing cheques And investing funds. Indemnity cover required for any previous business activity If 4.1 Are yes, Detail bank 2: please Cover statements. Shareholders/ provide details Receipts Principals.. Breakdown details Estate evaluate in the no. they..... have... been with.. your... firm Have you had any claims or losses? Residential Current Indemnity Sales Limit Current Excess Current If, please provide details:. Renewal Are the firm s annual current accounts policy: prepared..... by a firm Accountants? Retroactive : Industrial Level Commercial have certain Sales Indemnity rights access cover to you and require correction for quote this (tick information. Board This includes or REI/REAA any notifications disciplinary proceedings? claims. note that if you fail to make mention any claims or potential No claims, specify if a higher limit is required If, please specify provide if a higher details:. Body firm ever Corporate been declined Secretary/Management or has any such ever been cancelled or renewal refused or should Position be made aware? *lf If other, higher *lf higher please Lim Lim specify. are are required required please please the the Limit Limit required. required. Numbers: standard details:... excess is 5,000 plus GST. Name The and policy s address standard any excess Branch is 5,000 fices: plus GST. A Has higher there provide excess been number any is civil available or Administration criminal request allegations : at a. or on request (tick disciplinary. proceedings, or any Licensing Board alleging (tick. Employees law and against Contractors: the Company,... principals, Are References if it were obtained force? when engaging staff? Have If, any please personnel provide involved full details with the including firm been the name dismissed the for claimant, or as a result amounts dishonesty? paid for any.. If yes, please specify... Previous 12 months.. Estimate for the next 12 months What is the average Value Properties sold in the last 12 months..