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Design Matters National Management Liability Quote Request

Design Matters National Management Liability - Quote Request Form

Hidden
Fortix ID Opportunity
Name*
First Last
Business Name
ABN
Is your membership with Design Matters National current and paid for?*
- Yes
- No
Member Number*
Best Contact Number*
Email*
Address*
Street Address City State / Province / Region ZIP / Postal Code
Year Business Established*
Annual Turnover - Last Years Actual*
Number of Employees*
As a Director and/or Officer of the Company, are you aware of the legislation requirements relating to employment practices?*
- Yes
- No
Disclosure Questions
Do any directors of this company also hold directorships with any other company?*
- Yes
- No
Has any Director or Officer of the Company ever been declared bankrupt or entered into a deed of assignment, composition or scheme of arrangement with creditors?*
- Yes
- No
Has there been or is there now pending any disciplinary action, fine or penalty or any other claim made against any person proposed for insurance in their capacity as Director or Officer of the above Company or any other company, organisation, association or trust?*
- Yes
- No
Has any insurer ever declined to offer insurance, imposed any special terms or cancelled / voided any insurance for any Director / Company Officer or for this Company?*
- Yes
- No
Has there ever been, or is there now pending, any prosecution of the Company or its Subsidiaries, or any Director or Officer, under the Corporations Act, Competition and Consumer Act (or formerly the Trade Practices Act) or any other statute or legislation?*
- Yes
- No
Is any person proposed for insurance, after specific enquiry of management and staff, aware of, have knowledge or information of an incident, act, error or omission which may give rise to a claim of any kind that could be covered by the proposed insurance?*
- Yes
- No
If Yes, please provide further details*
Further Information
Do you have any other important information to add?
lease upload any relevant information if required
Max. file size: 32 MB.
Please take a moment to read these important documents prior to submission
- Click to view our Financial Services Guide
- Click to view our Privacy Policy
- Click to view your Duty of Disclosure Requirements
Please tick all to confirm that you have read the following documents:*
- Privacy Policy
- Financial Services Guide
- Important Notices
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.
This electronic signature will be treated the same as if signed personally.

Save and Continue Form Later

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© Copyright 2022 Webber Insurance Services

328A Magill Road, Kensington Park SA 5068

Webber Insurance Services Pty Ltd | ABN: 88 648 036 929 | CAR No: 413233

Authorised Representative of Webber Insurance Group Pty Ltd | AFSL: 488465 | ABN: 70 612 339 894 All rights reserved

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New insurance quotes or renewals for BDAA members who provide building design or energy rating (or similar) services.

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2. New Quote or Renewal?*

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