Professional Indemnity Renewal Declaration

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Work Request ID

Business Details

Name*

Business Name

ABN

Email*

Phone*

Website

Address*

About Your Business

Please describe your business services

Estimated Fees received for Professional Services for last 12 months*

Estimated Fees for Professional Services for next 12 months?*

Which states do you receive your income from?*

This is for the calculation of Stamp Duty only and does NOT reflect where in Australia you have policy coverage.

Estimated percentage of work undertaken in VIC*

Estimated percentage of work undertaken in NSW*

Estimated percentage of work undertaken in QLD*

Estimated percentage of work undertaken in SA*

Estimated percentage of work undertaken in WA*

Estimated percentage of work undertaken in TAS*

Estimated percentage of work undertaken in ACT*

Estimated percentage of work undertaken in NT*

Estimated percentage of work undertaken Overseas*

If overseas work is undertaken, please advise further details including countries involved.*

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

Coverage Changes

Do you need to make any changes to your existing policy coverage?*

Yes
No
Unsure

Please provide details on potential changes that need to be made for your renewal*

Claims Declaration

After enquiry, are any of the Partners, Principals, Directors or Employees aware of any claim, or fact, or circumstance which has the potential to give rise to a claim against the business?*

No, I have nothing new to notify
Yes, I have something new to notify
Yes, I have previously notified you

If yes, please provide further details*

Other Insurances

Do you require a quote on any alternative insurance covers that you do not currently hold with Webber Insurance?

If yes, 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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