Environmental Consultant Quote Request

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Fortix ID Opportunity

Your Information

Name*

Business Name

ABN

Best Contact Number*

Email*

Website

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*

Percentage of work done Overseas*

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 Environmental Works undertaken?*

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

Percentage of Acoustics & Noise Prevention Work*

Percentage of Asbestos Auditing Work*

Percentage of Asbestos Removal (including Project Management) Work*

Percentage of Building Inspections Work*

Percentage of Dangerous Goods Consulting/Auditing Work*

Percentage of Environmental Audits/Consulting/Engineering Work*

Percentage of Environmental Compliance Advice Work*

Percentage of Environmental Impact Assessment Work*

Percentage of General OH&S Consulting Work*

Percentage of Health & Safety Risks Assessment Work*

Percentage of Inspection & Testing of Machinery Work*

Percentage of Land Contamination Advice Work*

Percentage of Machinery & Heavy Vehicle Training/Ticketing Work*

Percentage of Mine Safety Consulting Work*

Percentage of Occupational Hygiene Consulting Work*

Percentage of Occupational Rehabilitation Consulting Work*

Percentage of OH&S Training (classroom based only) Work*

Percentage of Pollution – Consulting / Testing / Auditing / Other Work*

Percentage of Radiation - Consulting / Testing / Auditing / Other Work*

Percentage of Recycling Work*

Percentage of Safety Engineering Work*

Percentage of Site Remediation and Assessment Work*

Percentage of Soil Testing Work*

Percentage of Toxic Mould/Fungi Work*

Percentage of Wastewater Treatment Work*

Percentage of Water Quality Audits Work*

Percentage of Other Environmental Work*

If other, please provide details

Field of Work

Field of work undertaken?*

Please tick all that apply.

Percentage of Clean Energy Industry Work*

Percentage of Chemistry Work*

Percentage of Commercial Work*

Percentage of Construction Work*

Percentage of Local Authorities / Government Bodies Work*

Percentage of Manufacturing Work*

Percentage of Mining Industry Work*

Percentage of Other Utility Industry Work*

Percentage of Oil & Gas Industry Work*

Percentage of Power Industry Work*

Percentage of Residential Work*

Percentage of Water Industry 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.*

Limits of Cover Required

Professional Indemnity Limit of Cover Required*

If Other, please advise*

Are you currently insured for Professional Indemnity Insurance?*

Yes
No

If yes, please provide renewal date & current insurer*

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*

Contractors & Consultants

Do you engage any Consultants or Contractors to assist you in your business?*

Yes
No

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

How much is paid to consultants & contractors annually?*

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

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

On-Site Work

Do undertake any physical or manual work?*

Yes, our business does
Yes, but only our contractors do
Yes, both our business and contractors do
No, neither our business nor our contractors work on-site

If yes, please provide further information about on-site work*

Risk Management

Are verbal reports always confirmed in writing?*

Yes
No
We don't provide verbal reports

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

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 information*

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 information*

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 information*

Additional Information

Do you have any additional information to add?*

Yes I do
No I don't

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*

Other Insurances

Do you require a quote or further information about any of the following insurances?

If other. please advise 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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Environmental Consultant Quote Request

Your Information

About Your Business

NSW Stamp Duty Declaration

Work Undertaken

Field of Work

Limits of Cover Required

Contractors & Consultants

On-Site Work

Risk Management

Claims Experience

Additional Information

Other Insurances

Important Information

Declaration

Signature

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