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Professional Indemnity Insurance Quote Online Form

 

Please complete the following information and submit this form to obtain an insurance quotation for your business. Click on one of the following links if you would like to obtain a quote for your office insurance, public liability insurance or another type of insurance product.

 

All information you provide must be correct, true, and accurate as incorrect or misleading information may alter our quote and jeopardise cover if you proceed with a policy.

 

Please refer to the CGIB Financial Services Guide, Privacy Statement, General Advice Warning and Duty of Disclosure before completing this form.

INSURED'S & BUSINESS - Details
 

  Business Name*  

  Address*

 City/Town*

Post Code*

  Postal Address*

 City/Town*

Post Code*

No of Staff*

Website

Import/Export?   (does your business import or export goods?)
 

STATE / TERRITORY BREAKDOWN
 

Enter percentage of activities on fee income by State* (if nil please enter 0)

NSW VIC QLD SA WA TAS NT ACT O/Sea's TOTAL = 100%
 

ACTIVITY DESCRIPTION - Services
  Please list the categories of activities or business and indicate the percentage of your income derived from each category

Activity*

 % Worked *

Activity

 % Worked

Activity

 % Worked

Activity

 % Worked

Activity

 % Worked

Activity

 % Worked

Activity

 % Worked

Activity

 % Worked

Activity

 % Worked
                   Total 100%

State fully the nature of your business*

Business Annual Income - Total* $

 

 INSURANCE – Details
 

Professional Indemnity - Limit of Indemnity Sum Insured

Fidelity - Limit of Indemnity Sum Insured

$

 

 PREVIOUS INSURANCE - Details
 
Currently Insured? if yes, please provide the date it expirers / / & The Insurer*
 
  Please answer the following AFTER ENQUIRY of the partners, principals and directors of the insured:

  Has any Claim been made, or has any civil liability been alleged in the last tem (10) years against the business or any of

  their predecessors in business or any prior practice of any of their present or former Partners, Principals or Directors, or have 

  circumstances been notified to insurers that might give rise to a claim?

  Are there any circumstances not already notified to Insurers which may give rise to a Claim against any applicant?

 

  Has any applicant ever been refused this type of insurance or had similar insurance cancelled, or had an application or renewal

  declined, or had special terms imposed?

 

  Has any applicant ever been subject to disciplinary proceedings for professional misconduct?

 
   In the last 5 years, has any applicant been declared bankrupt?
   In the last 5 years, has any applicant been the subject of administration proceedings?
   In the last 5 years, has any applicant been convicted of any criminal offence (other than minor traffic convictions)?

 

 CONTACT – Details
 

First Name*

Surname*

  Phone No

   (please include area code)

  Fax No

   (please include area code)

Email Address*

 

How did you find us?*
if other, please provide details

 

 

 

 

 * Mandatory Fields

Thanks for completing our online form.

We will endeavor to contact you with your insurance details soon.

Meanwhile, if you require any further assistance please feel free to contact us.

            

                                                                                          

 

We may need to contact you to obtain additional information to assist us in providing you with a Business Insurance Quotation.

Completion of this form does not put an insurance policy/cover in place - you will need to contact us to arrange insurance cover.

All information you provide must be correct, true, and accurate as incorrect or misleading information may alter our quote and jeopardise cover if you proceed with a policy.

We recommend that you read the relevant Product Disclosure Statement when considering an insurance policy.