Design Matters National - New member Application Form

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Fortix ID Opportunity

Your Information

Name*

Business Name

ABN

Best Contact Number*

Email*

Website

Business Address*

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

Yes
No
No, but I am in the process of applying

Member Number*

If applicable, what date does your VBA registration expire?

Are you currently insured?*

Yes
No

Current Policy Expiry Date

Current Insurer

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 it is a new business, please select first option.

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 it is a new business, please select first option.

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 Victoria*

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 recieved 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

Are you a sole operator*

Yes
No

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

Details of your qualifications*

Is all work signed off by a qualified principal or partner*

Yes
No

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

Have you ever changed the name that you trade under*

Yes
No

Have you ever merged with or purchased another practice*

Yes
No

If yes, please provide further details*

Are you operating as a registered Architect?*

Yes
No
Unsure

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

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 projects are 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?*

None
$10,000,000
$20,000,000
Other

If other, please advise limit 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?*

Yes
No

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

Yes
No

If Yes, please provide further details*

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

Yes
No

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

Yes
No

If Yes, please provide further details*

Has any insurer ever cancelled or voided any Insurance held by YOU?*

Yes
No

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

Yes
No

If Yes, please provide further details*

Have YOU been charged with or convicted of any criminal offence?*

Yes
No

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

Yes
No

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 that you need to provide to the insurer?*

YES there is
NO there is not

If yes, please provide further information*

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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Your Information

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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