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Your Information
Name*
First Last
Business Name
ABN
Best Contact Number*
Email*
Address*
Street Address Suburb State Post Code Country
Are you a member of an association?*
- Yes
- No
Please tick all that apply*
- Design Matters
- ABSA / BDAA
- Other
If other, please advise*
Insurance Requirements
Are you currently insured?*
- Yes
- No
Current Insurer
Current Policy Expiry Date
Professional Indemnity Cover Required*
- $1,500,000 (Standard Cover - $480)
- $2,000,000
- $5,000,000
- Other
If other, please advise limit*
Do you also require Public Liability Cover?*
- $10,000,000 - ($120 extra)
- $20,000,000 - ($242 extra)
- No thanks
About Your Business
Total Fees Received - Last 12 Months Actual*

Gross Fees (Ex GST) should include all income received for your professional services including fees that are on-paid to Sub-Contractors.
What states do you receive your fees from?*
- NSW
- VIC
- QLD
- WA
- SA
- TAS
- NT
- ACT
- Overseas
Percentage of fees received in NSW*
Percentage of fees received in VIC*
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 ACT*
Percentage of fees received in NT*
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.
Type of Buildings Rated

Please state the approximate percentage of your Gross Professional Fee income derived from or relating to the following types of buildings
Domestic Residential Buildings (Includes Townhouses & Units)
Multi-Residential Apartments
Commercial Buildings
Municipal & Government Buildings
Other Buildings
If other, please advise further details*
Type of Services Provided
Please tick all services below that apply to you*
- House Energy Rating Assessments (HERS)
- Thermal Performance Assessments
- Commercial Energy Rating Assessments
- Home Sustainability Assessments
- Energy Efficiency Assessments
- Professional Advice Relating to the above services
- Quality Assurance Audits
- BASIX Certification
- Other Services not listed above
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*
Do you require coverage as a Victorian Residential Scorecard Assessor?*
- Yes
- No
To meet the requirements as a Victorian 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 Victorian Residential Scorecard Assessor?*
- Yes I do
- Not yet, my training is in progress
- No I don't
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, I have something to declare
- No, I have nothing to declare
Are YOU, AFTER FULL INQUIRY, aware of any circumstances which may give rise to a claim?*
- Yes, I have something to declare
- No, I have nothing to declare
If Yes, please provide further details*
If Yes, please provide further details*
Have YOU ever been subject to disciplinary proceedings for professional misconduct, any enquiry or audit?*
- Yes, I have something to declare
- No, I have nothing to declare
Has any insurer ever declined to offer Insurance of any type or imposed special terms for YOU?*
- Yes, I have something to declare
- No, I have nothing to declare
If Yes, please provide further details*
If Yes, please provide further details*
Has any insurer ever cancelled or voided any Insurance held by YOU?*
- Yes, I have something to declare
- No, I have nothing to declare
Is any partner/director/principal/employee connected or associated (financially or otherwise) with any other Practice or Business?*
- Yes, I have something to declare
- No, I have nothing to declare
If Yes, please provide further details*
If Yes, please provide further details*
Have YOU been charged with or convicted of any criminal offence?*
- Yes, I have something to declare
- No, I have nothing to declare
Have YOU been declared bankrupt, insolvent, had a liquidator appointed or been a defendant in any civil court case?*
- Yes, I have something to declare
- No, I have nothing to declare
If Yes, please provide further details*
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*
How did you hear about Webber Insurance?*
- Web Search
- Referred by Someone
- A Building Designer Association
- Social Media
- Previous / Existing Client
- Other
If other, please advise*
We appreciate referrals. Please let us know who provided you with our details*
Important Information

Please take a moment to read these important documents prior to submitting your form.
- Click to view our Privacy Policy
- Click to view our Financial Services Guide
- Click to view Duty of Disclosure Requirements
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
- Important Notices
Signature

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

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328A Magill Road, Kensington Park SA 5068

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

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