Design Matters National Existing Member Form

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Work Request ID

Your Information

Name*

Business Name

ABN

Best Contact Number*

Email*

Website

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

Yes
No

Business Address*

Is your membership with Design Matters current and paid for?*

Yes
No

VBA Registration Details

What date does your VBA registration expire?

Are you happy if we need to amend your insurance date to match your VBA registration date?*

Yes
No
Unsure, please provide more information
Not applicable - located outside of Victoria

With the introduction of the VBA 5 year renewal, we are endeavoring to match up your VBA and insurance renewal dates where possible to ensure there are no issues in the future.

Are you operating as a registered Architect?*

Yes
No
Unsure

About Your Business

Gross Fees - Last Years Actual*

$0 - $49,999
$50,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000 - $299,999
$300,000 - $399,999
$400,000 - $499,999
$500,000+

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

If over $500,000, please provide actual figure*

Gross Fees - Next Years Estimated*

$0 - $49,999
$50,000 - $99,999
$100,000 - $149,999
$150,000 - $199,999
$200,000 - $299,999
$300,000 - $399,999
$400,000 - $499,999
$500,000+

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

If over $500,000, please provide actual figure*

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Do you receive any fees for work done outside of Victoria?

Yes
No

What states do you receive fees from?*

*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 VIC*

Percentage of fees received in NSW*

Percentage of fees received in QLD*

Percentage of fees received in WA*

Percentage of fees received in SA*

Percentage of fees received in TAS*

Percentage of fees received in NT*

Percentage of fees received in ACT*

Percentage of fees received Overseas*

If overseas, please provide further details including countries fees received from*

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

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

Building Design Projects

Please select all project types below that your business provides*

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

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

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Percentage of Multi Level Residential Apartments Work

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Multi Level Residential Apartments

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Percentage of Commercial Buildings (Up to 3 storeys in height) Work

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

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Percentage of Nursing Homes, Hospitals, Medical Facilities and Aged Care Homes Work

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Percentage of Schools, Child Care Facilities, Municipal Buildings and Recreation Centres Work

Percentage of Other Work*

If you conduct other activities, please advise further details.*

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.*

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*

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

Please select all that apply.

If other, please provide further details*

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

If you are unsure, please provide further details*

Non-Disclosure Re Non-Conforming Building Materials
It is imperative that careful consideration be given to the above Non-Conforming Building Materials questions. If there is an incorrect statement or inadequate disclosure, such that the risk is underwritten by Insurers when with proper disclosure, the risk would have been declined, this will mean that any claim involving Non-Conforming Building Materials will be rejected by Insurers.

Type of Design Work Undertaken

Please select all services below that your business provides*

Building Design
Interior Design Work
Site Attendance & Contract Administration
Town Planning Services
Construction / Project Management
Accredited Energy Rating Assessments & Thermal Performance Assessments
Other

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Percentage of Building Design Work

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Percentage of Interior Design Work

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Percentage of Site Attendance & Contract Administration Work

What percentage of your overall income is from Construction / Project Management*

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Percentage of Accredited Energy Rating Assessments & Thermal Performance Assessments Work

Percentage of Other Work*

If Other services are provided, please advise further details*

Design & Construct

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

Yes
No

What Design & Construct services do you undertake?*

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*

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

Estimated turnover INCLUDING design and construction work for the next 12 months?*

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

Yes
No

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Estimated turnover earned from Construction only services

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Estimated fees/turnover earned from Design/Supervision only services

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Estimated fees/turnover earned from Other services

Limits of Cover

What limit of Professional Indemnity cover do you require?*

If other, please advise limit required*

What limit of Public Liability cover do you require?*

If other, please advise limit required*

Claims Experience

After all due and proper enquiries, I/We hereby declare that I/We am/are aware:

Of any incidents, facts or circumstances which may give rise to a claim against the firm, company or sole practitioner, its predecessors in business or any past or present partners, directors, principals, consultants or employees?*

Yes, I have something to notify
No, there is nothing to declare
I have previously declared an incident to my insurer and have nothing new to declare

If Yes, please provide further details*

Other Insurances

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

Office / Contents Insurance
Management Liability Insurance
Cyber / Privacy Protection Insurance
Motor Vehicle Insurance
Income Protection / Life Insurance
Construction / Contract Works Insurance
Tools / Mobile Equipment Insurance
Home Insurance
Other Insurance

If other, please provide further information*

Additional Information

Is there any other information or business changes that you need to provide to the insurer?*

YES there is
NO there is not

Please provide further details*

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:*

Privacy Policy
Financial Services Guide
Duty of Disclosure
Terms of Engagement

Signature

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

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Design Matters National Insurance Renewal Declaration

Your Information

VBA Registration Details

About Your Business

NSW Stamp Duty Declaration

Building Design Projects

Non-Conforming Building Materials

Type of Design Work Undertaken

Design & Construct

Limits of Cover

Claims Experience

Other Insurances

Additional Information

Important Information

Declaration

Signature

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