Energy Raters Renewal 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*

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

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

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*

What states do you receive your 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 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.

Click here to read more about this exemption

Type of Buildings Rated

Please select all building types below that are rated by your business*

Residential Houses
Townhouses & Units
Multi-Residential Apartments
Commercial Buildings
Municipal & Government Buildings
Other Buildings

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Domestic Residential Buildings (Includes Townhouses & Units)

Hidden

Multi-Residential Apartments

Hidden

Commercial Buildings

Hidden

Municipal & Government Buildings

Hidden

Other Buildings

If other, please advise further details*

Type of Services Provided

Please tick all services below that apply to you*

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 Residential Scorecard Assessor?*

Yes
No

To meet the requirements as a 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 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*

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*

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*

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*

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
Important Notices
Terms of Engagement

Signature

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

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