Construction Professionals Insurance Renewal Declaration

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Work Request ID

Your Information

Name(Required)

Business Name

ABN

Best Contact Number(Required)

Email(Required)

Website

Has your main business address changed in the past 12 months?(Required)

Yes

I am unsure, let me update it anyway

Main Business Address(Required)

Do you have any other business locations?(Required)

Yes

If yes, please provide further details(Required)

Business Activities

Are you currently a:(Required)

Building Designer

Interior Designer

Energy Rater / Thermal Performance Assessor

Registered Architect

Town Planner

Landscape Designer / Architect

Other Services

Please select all that apply.

If other, please provide further details(Required)

Have you undertaken any other services in the past listed above, or are you planning to undertake any of these other services in the future?(Required)

Yes

Which services apply?(Required)

Building Designer

Interior Designer

Energy Rater / Thermal Performance Assessor

Registered Architect

Town Planner

Landscape Designer / Architect

Other Services

Please select all that apply.

If other, please provide further details(Required)

Are you appropriately qualified to provide these services?(Required)

Yes

Please provide further details(Required)

Building Designer Information

As a building designer, are you registered in the states where you practice:(Required)

Yes I am

No, I don't need to

No, I am not

Do you have to register with Victorian Building Authority (VBA)?

Yes

Unsure

If yes, what is the date your VBA registration will expire

Are you operating as a registered Architect?(Required)

Yes

Building Design Projects

Please select all project types below that your business provides(Required)

Domestic Residential Buildings (Inc Multi-Level Townhouses & Units)

Multi Level Residential Apartments

Commercial Buildings (Up to 3 storeys in height)

Commercial Buildings (Exceeding 3 storeys)

Nursing Homes, Hospitals, Medical Facilities and Aged Care Homes

Schools, Child Care Facilities, Municipal Buildings and Recreation Centres

Other

What percentage of your projects are Commercial Buildings (Exceeding 3 Storeys)?(Required)

Percentage of Other Work(Required)

If you conduct other activities, please advise further details.(Required)

Other Work Undertaken

Our building design policy is intended to extend cover to energy rating services, interior design, town planning and contract administration services.
Please declare any services you undertake outside of those listed above.

Please select other services below that your business provides(Required)

Building Certification

Building Inspections

Construction / Project Management

Engineering Services

Other

NONE OF THE ABOVE

What percentage of your overall income is from Building Certification work(Required)

What percentage of your overall income is from Building Inspection work(Required)

What percentage of your overall income is from Construction / Project Management work(Required)

Percentage of Other work(Required)

If Other services are provided, please advise further details(Required)

Non-Conforming Building Materials

In the past 10 years, have you designed, certified, specified or recommended any building material that does not fully comply with all requirements for use in or on any commercial, industrial and/or residential structure as specified by the Building Code of Australia, and/or any other building code requirements of the relevant State or Territory, at the time of such design, certification, specification or recommendation?(Required)

Yes I have

No I haven't

I am not sure, can we discuss further

For further information on Non-Conforming Building Materials and to better understand what these products are, please refer here.

If yes, please advise what type of buildings this relates to(Required)

Residential Buildings – up to 2 stories in height

Residential Buildings – over 2 stories in height

Schools, Nursing Homes, Hospitals, Medical Facilities, Aged Care Homes, Child Care Facilities, Municipal Buildings and Recreation Centres

Other Commercial Buildings

Other Building Types - Not Listed Above

If other, please provide further details(Required)

Please provide details of these projects including types of materials, value of project and the size of the buildings(Required)

If you are unsure please provide further details(Required)

Please provide an overview of the largest 5 jobs you have undertaken in the past 5 years.(Required)

Design & Construct

Does your business undertake any construction services itself - i.e Design & Construct?(Required)

Yes

What Design & Construct services do you undertake?(Required)

We Design & Construct from OUR OWN DESIGN and provide full technical supervision of the build

We Construct from designs by OTHER PROFESSIONALS (building designers, architects, draftspersons etc.)

We Construct ONLY with NO DESIGN or professional service

Other (please specify)

Tick all that are applicable

Please advise other services(Required)

Actual turnover INCLUDING design and construction work for the last 12 months (please enter $0 if new business)?(Required)

Estimated turnover INCLUDING design and construction work for the next 12 months?(Required)

Do you have a separate Contract Works policy in place to cover your construction work?(Required)

Yes

Interior Design Projects

Location where work undertaken?

Residential Homes

Commercial Properties

Retail Properties

Industrial Properties

Other

Please click all that apply.

If you conduct other activities, please advise further details.(Required)

Interior Designer Information

Type of work currently undertaken:

Interior Decorator

Colour Consultant

Stylist

Interior Designer

Lighting Designer

Other

If other, please provide further details(Required)

Does your business undertake any property staging work?(Required)

Yes, we do it ourselves

Yes, we contract this service out

No, we do not provide this service

I am unsure

Do you sell any furniture, fixtures, fittings, or physical products of any nature?(Required)

Yes we do

No we do not

I am unsure

If yes, what was your turnover for the past 12 months selling these items?(Required)

Can you please confirm the types of products you’re selling/supplying?(Required)

Are any of these items you sell originally imported directly by you from overseas?(Required)

Yes it all is

Yes, some of it is

No, we do not import these items

I am unsure

If yes, please provide further details of the items imported(Required)

Are any of these items you sell exported overseas?(Required)

Yes it all is

Yes, some of it is

No, we do not export these items

I am unsure

If yes, please provide further details of the items exported(Required)

Energy Rating / Thermal Performance Assessor Information

Please select all building types below that are rated by your business(Required)

Residential Houses

Townhouses & Units

Multi-Residential Apartments

Commercial Buildings

Municipal & Government Buildings

Other Buildings

If other, please advise further details(Required)

Type of Services Provided

Please tick all services below that you undertake (or plan to undertake within the policy period)(Required)

Note that this policy will only provide cover for the activities listed below. This policy is not suitable if you also require cover for services including Building Design. We can cover this on a separate policy.

If other, please advise further details(Required)

Do you require coverage as a Residential Scorecard Assessor?(Required)

Yes

To meet the requirements as a Residential Scorecard Assessor, you must have $2,000,000 Professional Indemnity and $10,000,000 Public Liability covers. We can provide this cover for you.

Do you meet the requirements to be a Residential Scorecard Assessor?(Required)

Yes I do

Not yet, my training is in progress

No I don't

Architect Information

Type of Work undertaken?(Required)

Please check as many that are applicable to your line of work.

Percentage of Architecture Work(Required)

Percentage of Construction Management Work(Required)

Percentage of Drafting Work(Required)

Percentage of Heritage or Preservation Consulting Work(Required)

Percentage of Interior Design Work(Required)

Percentage of Landscape Architecture Work(Required)

Percentage of Modular Designs Work(Required)

Percentage of Pre-Purchase Inspections Work(Required)

Percentage of Project Management Work(Required)

Percentage of Soil Testing / Site Investigations Work(Required)

Percentage of Town Planning Work(Required)

Percentage of Work with Dams, Harbours & Jetties(Required)

Percentage of Work with Bridges, Mines, Tunnels or Offshore Projects(Required)

Percentage of Other Work(Required)

If other, please provide details

Work Undertaken

Type of Premises where work is undertaken?(Required)

Domestic

Commercial

Industrial

Institutional

High Rise

Other

Please tick all that apply.

Percentage of Domestic Work(Required)

Percentage of Commercial Work(Required)

Percentage of Industrial Work(Required)

Percentage of Institutional Work(Required)

Percentage of High Rise Work(Required)

Percentage of Dams Work(Required)

Percentage of Oil & Gas Work(Required)

Percentage of Other Work(Required)

If other, please provide details(Required)

Do you perform any of the following works?(Required)

Projects involving playgrounds

Golf Course or professional sports field work

NONE OF THE ABOVE

Non-Conforming Building Materials

Yes I have

No I haven't

I am not sure, can we discuss further

For further information on Non-Conforming Building Materials and to better understand what these products are, please refer here.

If yes, please advise what type of buildings this relates to(Required)

Residential Buildings – up to 2 stories in height

Residential Buildings – over 2 stories in height

Schools, Nursing Homes, Hospitals, Medical Facilities, Aged Care Homes, Child Care Facilities, Municipal Buildings and Recreation Centres

Other Commercial Buildings

Other Building Types - Not Listed Above

If other, please provide further details(Required)

Please provide details of these projects including types of materials, value of project and the size of the buildings(Required)

If you are unsure please provide further details(Required)

Please provide an overview of the largest 5 jobs you have undertaken in the past 5 years.(Required)

Design & Construct

Does your business undertake any construction services itself - i.e Design & Construct?(Required)

Yes

What Design & Construct services do you undertake?(Required)

We Design & Construct from OUR OWN DESIGN and provide full technical supervision of the build

We Construct from designs by OTHER PROFESSIONALS (building designers, architects, draftspersons etc.)

We Construct ONLY with NO DESIGN or professional service

Other (please specify)

Tick all that are applicable

Please advise other services(Required)

Actual turnover INCLUDING design and construction work for the last 12 months (please enter $0 if new business)?(Required)

Estimated turnover INCLUDING design and construction work for the next 12 months?(Required)

Do you have a separate Contract Works policy in place to cover your construction work?(Required)

Yes

About Your Business

Are you a member of an association?(Required)

Yes

No, but I am in the process of applying

Which association do you have a current membership with?(Required)

BDAA / ABSA

BDQ

Design Matters National

ATTMA

The IDA

AIA

DIA

AILA

Other

Click all that apply

BDAA / ABSA Member Number

BDQ Member Number

DMN Member Number

If other, please advise(Required)

Which association are you applying for membership with?(Required)

BDAA / ABSA

BDQ

Design Matters National

ATTMA

The IDA

AIA

DIA

AILA

Other

If other, please advise(Required)

How many staff do you have?(Required)

If over 10, please advise how many?

Details of all technical staff employed (including yourself) to carry out professional services

Please include Name, Qualification, Date Qualified and how long they have been with your business

Is all work signed off by a qualified principal or partner(Required)

Yes

If no, please detail why not and the risk management procedures in place to deal with technical staff errors(Required)

Sub-Contractors

Do you engage any Consultants or Contractors to assist you in your business?(Required)

Yes I do

No I don't

I am unsure

What type of work do these Contractors & Consultants do for your business?(Required)

Estimated amount paid to these Contractos & Consultants annually?(Required)

Do you require Insurance cover for your Consultants & Contractors?(Required)

Yes, for all of them

Yes, for some of them

No I don't

I am unsure

Please provide further details regarding the Contractor/s &/or Consultant/s that need Insurance cover.(Required)

Fee Information

Please select the actual range for your total Gross Fees (ex GST) over the PAST 12 months(Required)

Gross Fees (Ex GST) should include all income received for your professional services including fees that are on-paid to Sub-Contractors.

If over $1,000,000, please provide actual figure(Required)

Please select the projected range for your total Gross Fees (ex GST) expected for the NEXT 12 months(Required)

Gross Fees (Ex GST) should include an estimate of all income received for your professional services including fees that are on-paid to Sub-Contractors. If it is a new business and are unsure, please select the first option.

If over $1,000,000, please provide actual figure(Required)

What states do you receive your fees from?(Required)

*Please ensure that this field totals 100%. This split is required to calculate the correct Stamp Duty on your insurance policy, and is intended to be an estimate only of where you derive your income from.

Percentage of fees received in NSW(Required)

Percentage of fees received in VIC(Required)

Percentage of fees received in QLD(Required)

Percentage of fees received in WA(Required)

Percentage of fees received in SA(Required)

Percentage of fees received in TAS(Required)

Percentage of fees received in NT(Required)

Percentage of fees received in ACT(Required)

Percentage of fees received Overseas(Required)

If overseas, please provide further details including countries fees received from(Required)

NSW Stamp Duty Declaration

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 million(Required)

YES, my business turnover is LESS than $2,000,000

NO, my business turnover is GREATER 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.

Click here to read more about this exemption

Additional Business Information

Have you ever changed the name that you trade under(Required)

Yes

Have you ever merged with or purchased another practice(Required)

Yes

If yes, please provide further details(Required)

Do you envisage any substantial changes to your activities or are there any new major operations being contemplated in the next 12 months?(Required)

Yes

Is any Partner, Principal or Director connected or associated (financially or otherwise) with any other business?(Required)

Yes

If yes, please provide further details(Required)

Do you require cover for any principals in respect of their previous business/es?(Required)

Yes

If yes, please provide further details(Required)

Limits of Cover

What limit of Professional Indemnity cover do you require?(Required)

Same as last year

$1,000,000

$2,000,000

$5,000,000

$10,000,000

Other

If other, please advise limit required(Required)

What limit of Professional Indemnity cover do you require?(Required)

Same as last year

$1,000,000

$1,500,000

$2,000,000

$5,000,000

$10,000,000

Other

If other, please advise limit required(Required)

What limit of Public Liability cover do you require?(Required)

If other, please advise limit required(Required)

Other Insurances

Do you require a quote or additional information on any other insurances?

If other, please provide further information(Required)

Claims Experience

The term YOU in the questions below relates to your Firm, Company or you as a Sole Practitioner including present or former Partners, Directors, Principals, Consultants, or Employees.

During the past ten years has any claim been made, or has liability for an error or breach of duty been alleged against YOU; or have any circumstances been notified to insurers which may result in a claim?(Required)

Yes

Are YOU, AFTER FULL INQUIRY, aware of any circumstances which may give rise to a claim?(Required)

Yes

If Yes, please provide further details(Required)

Have YOU ever been subject to disciplinary proceedings for professional misconduct, any enquiry or audit?(Required)

Yes

Has any insurer ever declined to offer Insurance of any type or imposed special terms for YOU?(Required)

Yes

If Yes, please provide further details(Required)

Has any insurer ever cancelled or voided any Insurance held by YOU?(Required)

Yes

Is any partner/director/principal/employee connected or associated (financially or otherwise) with any other Practice or Business?(Required)

Yes

If Yes, please provide further details(Required)

Have YOU been charged with or convicted of any criminal offence?(Required)

Yes

Have YOU been declared bankrupt, insolvent, had a liquidator appointed or been a defendant in any civil court case?(Required)

Yes

If Yes, please provide further details(Required)

Additional Information

Is there any other information that you need to provide to the insurer?(Required)

YES there is

NO there is not

If yes, please provide further information(Required)

Important Information

Please take a moment to read these important documents prior to submitting your form.

Declaration

I/WE declare that we have read the important notices attached above and I/WE understand those notices.
I/WE undertake to inform insurers of any material alteration to these facts whether occurring before or after completion of the Contract of Insurance.
I/WE hereby acknowledge that the insurance cover may be provided in whole or in part by overseas insurers.

Please tick all to confirm that you have read the following documents:(Required)

Financial Services Guide

Duty of Disclosure

Terms of Engagement

Signature

This electronic signature will be treated the same as if signed personally.

Signature

Name

This field is for validation purposes and should be left unchanged.

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Construction Professionals Insurance Renewal Declaration

Your Information

Business Activities

Building Designer Information

Building Design Projects

Other Work Undertaken

Non-Conforming Building Materials

Design & Construct

Interior Design Projects

Interior Designer Information

Energy Rating / Thermal Performance Assessor Information

Type of Services Provided

Architect Information

Work Undertaken

Non-Conforming Building Materials

Design & Construct

About Your Business

Sub-Contractors

Fee Information

NSW Stamp Duty Declaration

Additional Business Information

Limits of Cover

Other Insurances

Claims Experience

Additional Information

Important Information

Declaration

Signature