Engineering Renewal Declaration

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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

Address*

About Your Business

Occupation*

Normal Duties*

Gross Fees - Projected this Financial Year*

Gross Fees - Last Financial Year

States where business is conducted?*

Percentage of work done in ACT*

Percentage of work done in NSW*

Percentage of work done in NT*

Percentage of work done in QLD*

Percentage of work done in SA*

Percentage of work done in TAS*

Percentage of work done in VIC*

Percentage of work done in WA*

If overseas, please advise further details of work undertaken*

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

Number of suitably qualified people in the business*

Details of their qualifications*

List the professional bodies or associations that you or the company belong to?

Is any Partner, Principal or Director connected or associated (financially or otherwise) with any other practice or business?*

Yes
No

If yes, please provide details*

Work Undertaken

Type of Engineering Works undertaken?*

Please check as many that are applicable to your line of work.

Percentage of Civil Engineering Work*

Percentage of Mechanical Engineering Work*

Percentage of Electrical Engineering Work*

Percentage of Structural Engineering Work*

Percentage of Chemical Engineering Work*

Percentage of Environmental Engineering Work*

Percentage of Process Control (PLC/SCADA) Work*

Percentage of Project Management Work*

Percentage of Construction Management Work*

Percentage of Other Engineering Work*

If other, please provide details

Process Control (PLC/SCADA) Additional Questions

How many years’ experience do you have in the design, installation and maintenance of SCADA/PLC systems?*

Are you working to a contract that includes written specifications?*

Yes
No

If not, why not?*

Do you perform user acceptance testing before migrating to a live environment?*

Yes
No

If not, why not?*

Do you have redundancy controls in place?*

Yes
No

If not, why not?*

Do you undertake any manual labour i.e. hot works, electrical installation etc.?*

Yes
No

If yes, please provide further details?*

Field of Work

Field of work undertaken?*

Please tick all that apply.

Percentage of Residential Buildings (1-2 Stories) Work*

Percentage of Residential Buildings (3 Stories & Above) Work*

Percentage of Commercial Buildings (1-2 Stories) Work*

Percentage of Commercial Buildings (3 Stories & Above) Work*

Percentage of Schools, Hospitals, Municipal Buildings Work*

Percentage of Industrial Work*

Percentage of Bridges & Tunnels Work*

Percentage of Dams Work*

Percentage of Oil & Gas Work*

Percentage of Mechanical Plant & Bulk Handling Equipment Work*

Percentage of HVAC Work*

Percentage of Temporary Structures Work*

Percentage of Waste Disposal, Treatment or Management Work*

Percentage of Water & Wastewater Work*

Percentage of Other Work*

If other, please provide details*

Please provide an overview of the largest 5 jobs you have undertaken in the past 5 years.*

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*

Residential Buildings – up to 2 stories in height
Residential Buildings – over 2 stories in height
Schools, Nursing Homes, Hospitals, Medical Facilities, Aged Care Homes, Child Care Facilities, Municipal Buildings and Recreation Centres
Other Commercial Buildings
Other Building Types - Not Listed Above

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.

Limits of Cover Required

Level of Cover Required*

Do you also require Public Liability Cover?*

Yes
No

If yes, what limit to do require?*

$5 million
$10 million
$20 million
Other

If other, please advise limit required*

Contractors & Consultants

Do you engage consultants, sub-contractors or agents?*

Yes
No

What type of work do these Contractors & Consultants do for your business?*

How much is paid to contractors annually?*

Do you insist they carry their own Professional Indemnity Insurance?*

Yes we do
No they dont
Some do, some don't

Risk Management

Are verbal reports always confirmed in writing?*

Yes
No

If No, how do you substantiate such verbal reports?

Do you enter into any hold-harmless agreements or otherwise waive any legal rights or entitlements which you may have against such consultants, sub-contractors or agents?*

Yes, we do
No, we don't
I am unsure

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

Hidden

Estimated turnover earned from Construction only services

Hidden

Estimated fees/turnover earned from Design/Supervision only services

Hidden

Estimated fees/turnover earned from Other services

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 information*

Other Insurances

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

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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Engineering Renewal Declaration Request

Engineering Insurance Renewal Declaration

Your Information

About Your Business

NSW Stamp Duty Declaration

Work Undertaken

Process Control (PLC/SCADA) Additional Questions

Field of Work

Non-Conforming Building Materials

Limits of Cover Required

Contractors & Consultants

Risk Management

Design & Construct

Claims Experience

Other Insurances

Additional Information

Important Information

Declaration

Signature

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