IT Liability Renewal Request

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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

Gross Fees - Projected this Financial Year*

Gross Fees - Last Financial Year*

States where business is conducted*

Percentage of fees received in ACT*

Percentage of fees received in NSW*

Percentage of fees received in NT*

Percentage of fees received in QLD*

Percentage of fees received in SA*

Percentage of fees received in TAS*

Percentage of fees received in VIC*

Percentage of fees received in WA*

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

Contractors & Sub-Consultants

Do you engage consultants, sub-contractors or labour hire personnel*

Yes
No

Are these consultants, sub-contractors or labour hire personnel required to hold their own insurance?*

Yes they are
No they dont
Some do, others don't

What is the work undertaken by these consultants, sub-contractors or labour hire personnel?*

Work Undertaken

In your own words, please provide a description of the work you do*

Please advise work undertaken (tick as many as applicable)*

Please ensure the total in the boxes below equals 100%

Percentage of Software Development &/or Installation work undertaken*

Percentage of Software Sales, (Packaged/Third Party) work undertaken*

Percentage of Software Sales (Own Developed) work undertaken*

Percentage of Hardware Sales work undertaken*

Percentage of Hardware Installation, Maintenance & Repair work undertaken*

Percentage of Systems Integration work undertaken*

Percentage of Data Processing / Warehousing Services work undertaken*

Percentage of IT Consulting (Excl IT Security) work undertaken*

Percentage of IT Education & Training work undertaken*

Percentage of IT Recruitment & Placement Services work undertaken*

Percentage of Network Consulting & Development work undertaken*

Percentage of Cyber Security Sevices work undertaken*

Percentage of IT Systems Analysis & Testing work undertaken*

Percentage of Search Engine Optimisation work undertaken*

Percentage of IT Project Management work undertaken*

Percentage of IT Systems Audit work undertaken*

Percentage of IT Help Desk & Network Support work undertaken*

Percentage of Website Design work undertaken*

If other, please provide details*

Percentage of Other work undertaken*

Do you perform any work in relation to the following*

If yes, please provide further details*

Cover Required

Level of Professional Indemnity Cover Required*

If other, please advise limit?*

What level of Public Liability cover do you need?*

If other, please advise*

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, there is 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, there is 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, there is nothing to declare

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, I have something to declare
No, there is 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, there is 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, there is 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, there is nothing to declare

If Yes, please provide further details*

Other Insurances

Do you require a quote or further information on any of the following types of insurance?

Cyber Insurance
Business Insurance
Workers Compensation
General Property (Laptops etc)
Income Protection
Life Insurance
Motor Vehicle
Other

If other, please advise

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
Duty of Disclosure
Terms of Engagement

Signature

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

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IT Liability Insurance Renewal Request

Your Information

About Your Business

NSW Stamp Duty Declaration

Contractors & Sub-Consultants

Work Undertaken

Cover Required

Claims Experience

Other Insurances

Additional Information

Important Information

Declaration

Signature

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