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1Your Details

2Business Details

3Business Activities

4Cover Required

5Disclosure Questions

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Fortix Opportunity ID

Your Information

Name*

First Last

Business Name

ABN

Best Contact Number*

Email*

Website

Address*

Street Address City State / Province / Region ZIP / Postal Code

About Your Business

Occupation*

Normal Duties*

Gross Fees - Projected this Financial Year*

Gross Fees - Last Financial Year

States where business is conducted?*

ACT

NSW

NT

QLD

SA

TAS

VIC

WA

Overseas

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*

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 Insurance?*

Yes we do

No we don't

Some do, some don't

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

Work Undertaken

Type of Engineering Works undertaken?*

Civil Engineering

Mechanical Engineering

Electrical Engineering

Structural Engineering

Chemical Engineering

Environmental Engineering

Process Control (PLC/SCADA)

Heating, Ventilation, Air Conditioning, Hydraulics & Plumbing (HVAC)

Project Management

Construction Management

Other

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 HVAC 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?*

Residential Buildings (1-2 Stories)

Residential Buildings (3 Stories & above)

Commercial Buildings (1-2 Stories)

Commercial Buildings (3 Stories & above)

Schools, Hospitals, Municipal Buildings

Industrial

Bridges & Tunnels

Dams

Oil & Gas

Mechanical Plant & Bulk Handling Equipment

Temporary Structures

Waste Disposal, Treatment or Management

Water and Wastewater

Other

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 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.

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

Does your business undertake any other manual or physical work i.e. installation, manufacture, assembly, product sales etc.*

Yes

No

Unsure

If yes, please provide further details*

Limits of Cover Required

Professional Indemnity Limit of Cover Required*

$1 Million

$2 Million

$5 Million

$10 Million

$20 Million

Other

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*

Other Insurances

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

Office / Contents Insurance

Management Liability Insurance

Cyber / Privacy Protection Insurance

Motor Vehicle Insurance

Drone Insurance

Income Protection / Life Insurance

Construction / Contract Works Insurance

Tools / Mobile Equipment Insurance

Home Insurance

Other Insurance

If other. please advise further information*

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*

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*

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*

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*

Important Information

Please take a moment to read these important documents prior to submitting your form.

Click to view our Privacy Policy
Click to view our Financial Services Guide
Click to view Duty of Disclosure Requirements
Click to view Terms of Engagement

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.

Signature

Comments

This field is for validation purposes and should be left unchanged.

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Professional Indemnity

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"*" indicates required fields

1Your Details

2Quote Details

Type of Work Undertaken*

Estimated Fees - Next 12 Months*

Professional Indemnity Limit*

Public Liability Cover Required*

Business Name*

If other, please advise*

If combination, please advise*

Name*

First Last

Email*

Phone*

Postcode*

Contact us on 1300 932 237 for tailored advice.