Accounting Insurance Renewal Declaration

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Work Request ID

Your Information

Name*

Business Name

ABN

Email*

Phone*

Website

Has your business address changed in the past 12 months?*

Yes
No

Business Address*

About Your Business

Number of Staff (including Directors)*

Name of Key Staff including Directors & Qualifications Held*

Gross professional fee income for last 12 months*

Estimated professional fee income for next 12 months*

Which states do you receive client fees from?*

An estimation only of where you receive your income from, in order to calculate the correct Stamp Duty on your insurance policy

Percentage of work done in NSW*

Percentage of work done in VIC*

Percentage of work done in QLD*

Percentage of work done in SA*

Percentage of work done in WA*

Percentage of work done in TAS*

Percentage of work done in NT*

Percentage of work done in ACT*

Percentage of work done Overseas*

If overseas work, please advise the type of work and the countries where work is undertaken?*

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*

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 million

Click here to read more about this exemption

Business Activities

Type of Accounting work the Firm has undertaken in the PAST 12 months?*

If a new business, please provide estimates for next 12 months

Accounts Preparation

Percentage of Accounts Preparation work*

Auditing

Overall percentage of Auditing work?*

Type of Auditing work undertaken*

Percentage of Public Listed Companies work*

Percentage of Public Unlisted Companies work*

Percentage of Small Private Companies work*

Percentage of Large Private Companies work*

Percentage of Non Profit Organisations work*

Percentage of Financial Institutions work*

Percentage of Trust Funds and/or Executorships work*

Percentage of Superannuation Funds (General) work*

Percentage of SMSF work*

Percentage of Other work*

Please provide details of other work*

Please provide Business Names, Nature of Business and Annual Fees for your 5 largest audit clients*

Bookkeeping

Percentage of Bookkeeping work*

Taxation

Percentage of Taxation work*

BAS

Percentage of BAS work*

Business Valuations

Percentage of Business Valuation work*

How many valuations do you undertake per annum?*

Please provide details and qualifications of Principals or Staff that undertake business valuations*

What type of valuations do you provide?*

Business Valuations
Valuations of Equity in Business
Profitability Assessments
Pre-Purchase Reviews
Other

If other, please advise further details*

Please provide an overview of the purpose of these valuations along with whom they were done for in the past 12 months?*

Superannuation Fund Management / Trusteeship / Administration

Percentage of Superannuation Fund Management / Trusteeship / Administration work*

Is the Superannuation Fund for the benefit of the Firm's Principals or Staff?*

Yes
No

Is the Superannuation Fund invested at the discretion of the Firm for Principals or Staff?*

Yes
No

If yes, where is it invested?*

Is the Superannuation Fund for the benefit of the Firm's Clients?*

Yes
No

Is the Superannuation Fund invested at the discretion of the Firm for Clients?*

Yes
No

If yes, where is it invested?*

Do the Firm's clients have knowledge of the type of investment in the Fund/s and formally confirm their acceptance?*

Yes
No

Does the Firm manage the funds by way of a trust account to be passed onto a recognised fund at the clients' direction?*

Yes
No

Has the Firm established predetermined investment criteria with the clients?*

Yes
No

Do any Partners, Principals or Staff act as Trustees of any clients' Superannuation Funds?*

Yes
No

If yes, please provide further details*

Forensic Accounting

Percentage of Forensic Accounting work*

Management Consultancy

Percentage of Management Consultancy work*

Please elaborate on the nature of activities undertaken and advice given to clients*

Company Directorships

Percentage of Company Directorships work*

If yes, please provide further details including Company details, Position and Length of Time involved*

Business / Mortgage / Finance Broking

Percentage of Business / Mortgage / Finance Broking work*

Financial Planning, Investment Advice / Management

Percentage of Financial Planning, Investment Advice / Management work*

Mergers & Acquisitions

Percentage of Mergers & Acquisitions work*

Receivership's, Liquidations or Insolvencies

Percentage of Receivership's, Liquidations or Insolvencies work*

Other

Percentage of Other work*

Please provide further details of your Other activities*

Changes to Business Activities

Will there be any known significant changes to your business activities for the NEXT 12 months?*

Yes
No

If yes, please provide further details*

Have you ceased providing any of the above services in the past 5 years?*

Yes
No

If yes, please provide further details*

Limits of Cover Required

Level of Cover Required*

If other, please specify*

Do you also require Public Liability Cover?*

Yes
No

Level of Cover Required*

$5 million
$10 million
$20 million
Other

If other, please specify*

Optional Covers

Do you require cover for any of the following extensions?*

Fidelity
Previous Business
Outgoing Principals
Public Liability
NONE OF THE ABOVE

Fidelity

Has the business sustained any loss through the fraud or dishonesty of any employee?*

Yes
No

Is any member of your staff allowed to handle cash or transferable documents or sign cheques on his/her signature alone?*

Yes
No

Do you always require and obtain satisfactory references when engaging employees?*

Yes
No

If yes, please provide further details*

Previous Business

Please provide further details regarding the previous business (es) that need to be covered under this policy*

Outgoing Principals

Please provide details, including Retirement Date, of Partners, Directors or Principals who have retired and require this extension.*

Risk Management

Do any Contractors or Consultants do any work on behalf of your firm?*

Yes
No

If yes, please provide further details as to the nature of work undertaken by these Contractors or Consultants*

Do you require each Contractor, Sub-Contractor or Consultant to have their own Professional Indemnity cover in place?*

Yes
No
Other

If other, please provide further information*

What are the Gross Professional Fees paid to these Contractors, Sub-Contractors or Consultants?*

Does any contract or client represent more than 25% of your annual work?*

Yes
No

Do you always obtain your client's signed retainer agreement?*

Yes
No

If yes, please provide further details*

If no, by what other means do you record your retainer?*

Do you always provide written advice (including valuations/assessments) with appropriate disclaimers?*

Yes
No

If no, by what other means do you record your advice?*

Previous History

Have you ever made a claim on this type of insurance policy?*

Yes I have
No I have not

Are you aware of any claim, fact or circumstance which could give rise to a claim against the business, its directors & management or yourself if a sole trader?*

Yes I am
No I am not
I have already notified you of a matter

Have you ever been subject of a disciplinary hearing for professional misconduct?*

Yes I have
No I have not

Have you ever been had an insurer decline to offer this type of insurance to you*

Yes I have
No I have not

Have you ever been had an insurer cancel or void this type of policy or apply special terms?*

Yes I have
No I have not

Have you ever been convicted of a criminal matter*

Yes I have
No I have not

Have you ever been had an insurer cancel or void this type of policy*

Yes I have
No I have not

Have you ever been bankrupt or insolvent either personally or as a company director*

Yes I have
No I have not

If yes to any of the above, please provide further details for each*

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Has any insurer ever declined to offer Insurance of any type for this Firm, Company or Sole Practitioner or for any Partner, Director or Principal?

Yes
No

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Has any insurer ever imposed any special terms on this Firm, Company or Sole Practitioner or any Partner, Director or Principal?

Yes
No

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If yes, please advise further details:*

Hidden

If yes, please advise further details:*

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Please advise what level of Public Liability cover is required?

Hidden

Has any insurer ever cancelled or voided any Insurance held by this Firm, Company or Sole Practitioner or any Partner, Director or Principal?

Yes
No

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Have you or any Partner/Principal/Director/staff member ever been subject to disciplinary proceedings for professional misconduct?

Yes
No

Hidden

If yes, please advise further details:*

Hidden

If yes, please advise further details:*

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During the past ten years has any claim been made, or has liability for an error or breach of duty been alleged against the Firm, Company or Sole Practitioner or any of their predecessors in business or any prior Entity or any of their present or former Partners, Directors, Principals, Consultants, or Employees; or have any circumstances been notified to insurers which may result in a claim?

Yes
No

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Are any of the Partners, Directors, Principals or Employees AFTER FULL INQUIRY, aware of any circumstances which may give rise to a claim against the Firm, Company or Sole Practitioner, its predecessors in business or any past or present Partner, Director, Principal, Consultant, or Employee?

Yes
No

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If yes, please advise further details:*

Hidden

If yes, please advise further details:*

Other Information

Are there any other matters that are material to your situation that the insurer should be aware of?

Confirmation of Details

Please tick all to confirm that you have read the following documents:*

Financial Services Guide
Privacy Policy
Duty of Disclosure
Terms of Engagement

Signature

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

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Accountants Insurance Renewal Request

Your Information

About Your Business

NSW Stamp Duty Declaration

Business Activities

Accounts Preparation

Auditing

Bookkeeping

Taxation

BAS

Business Valuations

Superannuation Fund Management / Trusteeship / Administration

Forensic Accounting

Management Consultancy

Company Directorships

Business / Mortgage / Finance Broking

Financial Planning, Investment Advice / Management

Mergers & Acquisitions

Receivership's, Liquidations or Insolvencies

Other

Changes to Business Activities

Limits of Cover Required

Optional Covers

Fidelity

Previous Business

Outgoing Principals

Risk Management

Previous History

Other Information

Confirmation of Details

Signature