(03) 9967 1400
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Your Gross Income/Fees

(Australian Dollars)

Your Primary State of Operation

Do you perform any of the following services?

  • Audit Listed Entities or Financial Institutions
  • Insolvencies / Liquidations
  • Mergers & Acquisitions Transactions
  • (Financing, legal or debt finance, capital raising, equity for control exchange, or debt for equity exchange.)

Have you had any claims in the past 5 years?

Professional Indemnity Insurance

Limit of Indemnity

Optional Add-Ons

Limit Required
Limit Required

Itemised Breakdown

Professional Indemnity 0.00

- $2 Millon Limit

Cyber Insurance 0.00

- $500k

Public Liability 0.00

$10 Millon

Stamp Duty, GST &
other Fees 0.00

Total

0.00

14 Months Cover

* Estimates Includes all taxes & fees Estimates are indications only and are subject to submission of a completed application form, and final pricing and approval by the underwriter.

Applicant Details

1. Entities to be Insured

Only specified entities will have insurance cover. It is therefore essential you add any additional entities, registered names and Trading names by selecting + Add Entity

2. Contact Details

3. Gross Income/Fees (Australian Dollars)

4. Stamp Duty

For the purpose of calculating the stamp duty to be paid for the policy, please provide the approximate percentage of the Applicants’ activities (based on gross income/fees in the previous financial year) applicable to each state, territory and overseas. (TOTAL must equal 100%).

Do you qualify for NSW Stamp Duty Exemption as a CGT small Business?

5. When Would You Like Your Insurance to Commence?

Itemised Breakdown

Professional Indemnity 0.00

- $2 Millon Limit

Cyber Insurance 0.00

- $500k

Public Liability 0.00

$10 Millon

Stamp Duty, GST &
other Fees 0.00

Total

0.00

14 Months Cover

* Estimates Includes all taxes & fees Estimates are indications only and are subject to submission of a completed application form, and final pricing and approval by the underwriter.

Resources

6. Staff

Please indicate the number of employees, sub-contractors and consultants employed/engaged by the Applicant for each category.

7. Principals, Directors & Partners

Please provide each principal / partner / directors details

Years practicing as a

principal / partner / director.

8. Professional Memberships

a) Please list the professional body/s or Association/s of which the insured is a member and/or holds a Certificate of Public Practice for:

b) Has the insured ever been disqualified, expelled or deregistered by a Professional Body / Association or Regulator?

If yes, please provide details:

9. General Information

a) Has the insured been involved in any mergers, acquisitions or Joint Ventures in the last 5 years?

If yes, please provide details:

b) Is previous business cover required for the previous business of any principal, director or partner?

If Yes, please advise Names of Principal(s), names of business(es) & services provided:

c) Does the insured have an Australian Financial Services License?

If yes please state AFSL Number:

10. Activities Breakdown

Please provide a breakdown of your fees derived from the following activities:

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%

Total (Must Equal 100%)

%

Itemised Breakdown

Professional Indemnity 0.00

- $2 Millon Limit

Cyber Insurance 0.00

- $500k

Public Liability 0.00

$10 Millon

Stamp Duty, GST &
other Fees 0.00

Total

0.00

14 Months Cover

* Estimates Includes all taxes & fees Estimates are indications only and are subject to submission of a completed application form, and final pricing and approval by the underwriter.

Insurance History

11. Latest Professional Indemnity Policy

12. Prior Claims or Circumstances

In the last 5 years has any partner, principal, director, employee, sub-contractor or consultant ever been subject to disciplinary proceedings for professional misconduct?

Please provide details of ALL disciplinary proceedings:

Have any claims for negligence or breach of professional duty ever been made against the Firm or the Firm’s predecessor, or against any of the Partners or Directors who are or were a partner or director?

Important notice: When completing the table below, the amount indicated in Amount Paid should reflect any payments already made by the Insurer to third parties, plus any legal costs and expenses incurred to date by the insurer. The amount indicated in Estimated should include amounts set aside by the Insurer for possible future payments. This information should be available directly from your Insurer's claims department.

Please provide a brief description of the claim/loss/notification

After inquiry, is the Firm or are any of the Partners or Directors aware of any circumstances which may result in a future claim being made against the Firm, the Partners or Directors, or against any other Firm of which any of the Partners or Directors is or was a partner or director?

Please provide a brief description of the circumstance(s):

Has the firm sustained any loss, or does it know of any possible loss through fraud or dishonesty of any director, partner, principal or employee of the firm?

If yes, please provide details:

Cyber Claims and Incidents

During the past three years, has the firm experienced a cyber incident, claim or loss, whether insured or not, which could have been covered under a cyber policy?

This includes;
  1. any actual or reasonably suspected data breach or security failure requiring notification of consumers or third parties;
  2. any claims or complaints relating to privacy injury, breach of information or network security, unauthorised disclosure of information, defamation, or content infringement;
  3. any government action, investigation, or subpoena concerning an alleged violation of a privacy law or regulation, or;
  4. any actual or attempted extortion demand involving the Insured’s data or computer system

Please describe the relevant cyber incidents and/or claim(s)

13. Signatories

Is any person who is not a director, partner or principal authorised to transfer funds, or to sign checks with their authorisation or signature alone?

If yes, please provide the name of the person so authorised

Does the firm require a secondary means of communication to validate the authenticity of:

a) Funds transfer requests before processing a request in excess of $5,000?

b) Any request to change banking details?

Itemised Breakdown

Professional Indemnity 0.00

- $2 Millon Limit

Cyber Insurance 0.00

- $500k

Public Liability 0.00

$10 Millon

Stamp Duty, GST &
other Fees 0.00

Total

0.00

14 Months Cover

* Estimates Includes all taxes & fees Estimates are indications only and are subject to submission of a completed application form, and final pricing and approval by the underwriter.

Declaration

I declare that I have read and understood the duty of disclosure notice contained in the Important Notices, and that all statements and particulars in this proposal form are true, and that after enquiry, no material facts have been mis-stated or suppressed. I further agree that should any of the information given by me alter between the date of the proposal and the inception date of the insurance to which this proposal relates, I will give immediate notice to PLI Brokers who will refer it to the underwriters. I also consent to the use and disclosure of my personal information (and that of any other persons to whom this application relates) solely in accordance with PLI Brokers Privacy Policy. I agree that this proposal, together with any other information supplied by me shall form the basis of any contract of insurance effected thereon.

TO BE AGREED UPON BY THE INSURED PARTY FOR WHOM THIS POLICY IS INTENDED:

Click here to confirm that you have read, understood, and agree to the above declaration, and further that you agree to all documentation being delivered to you electronically.
Click here to confirm that you have read and understood the statement(s) below.
You have advised you provide Company Secretarial Services. Your policy does provide cover, but only company secretarial administrative tasks undertaken for a fee levied by the insured. Should the Insured act in the capacity of a director or officer or take these appointments in external companies, there is no cover under this policy.
You have advised you provide business valuations & accounting services related to Mergers & Acquisitions. Our policy provides cover for the following activities;
  • Financial Due diligence
  • Tax due diligence
  • Accounting and compliance reviews
  • Assisting with valuation methods
The following are NOT covered under this policy;
  • Deal Structuring
  • M&A integration accounting
  • Debt & capital structuring
  • Regulatory or compliance related to M&A
  • Legal advice and services
  • Project Management and transaction implementation
You have advised you provide Management Consultancy Services. Your policy provides cover for such services including analysis and identification of a third party's management, operational, business, communication, information, training and marketing procedures and interests. This includes consideration of goals, objectives, policies, strategies, planning, logistics, recruitment and staffing and providing recommendations of solutions to address issues arising out of such analysis and consideration. Please note this cover;
  • Excludes investment advice
  • Excludes Mergers and Acquisitions advice.
You have advised you provide Self-Managed Superannuation Fund Administration services. Your policy DOES provide cover for these services however this cover does NOT extend to include;
  • Superannuation Fund management activities
  • Investment management activities
  • Asset management activities
  • Custodian activities

Itemised Breakdown

Professional Indemnity 0.00

- $2 Millon Limit

Cyber Insurance 0.00

- $500k

Public Liability 0.00

$10 Millon

Stamp Duty, GST &
other Fees 0.00

Total

0.00

14 Months Cover

* Estimates Includes all taxes & fees Estimates are indications only and are subject to submission of a completed application form, and final pricing and approval by the underwriter.

Save Your Progress

We will email you a link to your application form. You can still complete the application by selecting ‘Continue’.

Save & Exit Save & Continue

Itemised Breakdown

Professional Indemnity 0.00

- $2 Millon Limit

Cyber Insurance 0.00

- $500k

Public Liability 0.00

$10 Millon

Stamp Duty, GST &
other Fees 0.00

Total

0.00

14 Months Cover

* Estimates Includes all taxes & fees Estimates are indications only and are subject to submission of a completed application form, and final pricing and approval by the underwriter.