Interior Designer Quote Request Form

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Fortix ID Opportunity

Your Information

Name*

Business Name

ABN

Best Contact Number*

Email*

Website

Business Address*

Business Information

Are you a member of an association?*

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

Association memberships*

BDAA
BDQ
Design Matters
DIA
The IDA
Other

If other, please advise*

As an interior designer, are you registered in the states where you practice:*

Yes I am
No, I don't need to be registered
No, I am not

Have you ever changed the name that you trade under*

Yes
No

If yes, please provide further details*

Have you ever merged with or purchased another practice*

Yes
No

If yes, please provide further details*

Are you currently insured?*

Yes
No

Current Policy Expiry Date

Current Insurer

About Your Business

How many staff do you have?*

If over 10, please advise how many?

Gross Fees - Last Years Actual*

Nil, this is a new business
$0 - $75,000
$75,001 - $150,000
$150,001 - $200,000
$200,001 - $300,000
$300,001 - $400,000
$400,001 - $500,000
$500,001 - $600,000
$600,000+

Gross Fees (Ex GST) should include all income received for your professional services including fees that are on-paid to Sub-Contractors.

If over $600,000, please provide actual figure*

Gross Fees - Next Year Estimated*

$0 - $75,000
$75,001 - $150,000
$150,001 - $200,000
$200,001 - $300,000
$300,001 - $400,000
$400,001 - $500,000
$500,001 - $600,000
$600,000+

Gross Fees (Ex GST) should include an estimate of all income received for your professional services including fees that are on-paid to Sub-Contractors. If it is a new business and are unsure, please select the first option.

If over $600,000, 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 NT*

Percentage of fees received in ACT*

Percentage of fees received Overseas*

If overseas, please provide further details including countries fees received 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 Work Undertaken

Type of Work Undertaken*

Interior Decorator
Interior Designer
Colour Consultant
Lighting Designer
Stylist
Other

Please click all that apply.

If other, please advise*

Interior Design Projects

Location where work undertaken?

Residential Homes
Commercial Properties
Retail Properties
Industrial Properties
Other

Please click all that apply.

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Percentage of overall work that is Commercial Properties

Hidden

Percentage of overall work that is Environmental Design

Hidden

Percentage of overall work that is Multi-Unit Developments

Hidden

Percentage of overall work that is Residential Houses work

Hidden

Percentage of overall work that is Retail work

Hidden

Percentage of overall work that is Other Work

If you conduct other activities, please advise further details.*

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*

Sub-Contractors

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

Yes I do
No I don't
I am unsure

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

Do you require Public Liability cover for your Consultants & Contractors?*

Yes, for all of them
Yes, for some of them
No I don't
I am unsure

Please provide further details regarding the Contractor/s &/or Consultant/s that need Public Liability cover.*

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*

How did you hear about Webber Insurance?*

Web Search
Referred by Someone
An Interior 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.

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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Interior Designer Insurance Quote Request

Your Information

Business Information

About Your Business

NSW Stamp Duty Declaration

Type of Work Undertaken

Interior Design Projects

Limits of Cover

Sub-Contractors

Other Questions

Claims Experience

Other Insurances

Additional Information

Important Information

Declaration

Signature

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