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Professional Indemnity Insurance
ACCOUNTANTS AND AUDITORS

AUSTRALIAN & NEW ZEALAND NATIONWIDE INSURANCE SERVICES
Sydney • Brisbane • Melbourne • Adelaide • Perth • Wellington • Auckland

Accountant & Auditor - Professional Indemnity Insurance

PROPOSAL FORM

This form is designed to gather general information from which to present to various underwriters to obtain an indicative quote. You might have to provide further information in due course.

If your Professional Indemnity requirements exceed the scope of this form, please contact us for direct personal assistance.

Terms and Conditions

Please ensure all required fields are filled in. They have been highlighted in red for your convenience.

PROPOSER DETAILS -

Section 1


		Please provide the full legal name of all entities to be insured under the Policy
Name of the Proposer

What is the Trading Name? [if different to the above question]

Is the Proposer a Company, Partnership or Individual?

ABN or Other Business Registration Number

Date of Establishment of the Proposer's Business

Address of where your Business is situated - Head Office [Include Postcode and State]

Postal address of Head Office if different from above [Include Postcode and State]

Business Telephone [Include Area Code]

Facsimile [Include Area Code]

Mobile

Email Address
Re-Enter Email Address

The Proposer's Website:

ACCOUNTING PRACTICE DETAILS-

Section 2

Please provide a precise description of the Proposers' accounting/auditing practise.

Does the Proposer perform or has the
Proposer in the past performed auditing work
for any public company, financial institution,
insurance company, insurance underwriting agency, merchant bank, finance house or
credit sales organisation.

Yes No

Does the Proposer intend to perform such
work in the future.

Yes No

If Yes, to either question above please provide details

Is the Proposer licensed under Corporations Law to carry on the business of :


Securities Dealer	Yes No
Investment Adviser	Yes No
Financial Planning	Yes No
Tax Agent	Yes No

Does the Proposer provide advice on:


Setting up captives	Yes No
Offshore investments	Yes No

If Yes, in either case please provide details

Has a partner, principal or employee
of the Proposer ever been a partner,
principal or employee of any of the
following firms:

   a)    Arthur Anderson
   b)    Deloitte Touche
   c)    Ernst & Young
   d)    Price Waterhouse Coopers
   e)    KPMG
   f)    or any individual or merged combination:

Yes No

If Yes, to either case please provide details

Does any Partner, Principal or Director of the Proposer have any connection or association (financially or otherwise) with any other similar business or practice?

Yes No

If Yes, please provide details

Please state the approximate percentage of the Proposer's fee income derived from the following types of work.

Activity	% of fee income	% of fee income
	Past 12 mths	Est Next 12 mths
1 Preparation of accounts
2 Taxation
3 Examination of business and company accounts
4 Investment management services, advice and financial planning
5 Insolvency, liquidation and receivership
6 Superannuation fund management / trusteeships and executorships
7 Work for banks, finance houses, hire purchase and credit sales organisations and other concerns providing finance

8 Insurance agency
9 Audit of private companies
10 Audit of public companies
11 Directorship positions
12 Management consultancy (give details)
13 All other work give details..

Have there been any substantial changes in the Proposer's business activities in
the past 12 months?
If Yes, please provide details.

Yes No

Does the Proposer expect any significant changes in business activities in the next 12 months?
If Yes, please provide details.

Yes No

Is the Proposer, a current financial member in good standing of a
Professional Association?
If Yes, please provide details.

Yes No

In the past 5 years, has the name
of the Proposer ever changed?
If Yes, please provide details.

Yes No

In the past 5 years, has the
Proposer purchased, merged or
amalgamated with another
similar business?
If Yes, please provide details.

Yes No

In the past 5 years, has the Proposer been involved in any
joint ventures?
If Yes, please provide details.

Yes No

Does the Proposer engage subcontractors? Yes No
	If Yes, please state gross fees paid to Subcontractors:-
	Previous Financial Year	Est. Current Financial Year	Est. Next Financial Year
	$	$	$

Are subcontractors required to carry their own Professional Indemity Insurance? If No, please provide details.		Yes No

Does the Proposer perform any work outside Australia, or work for clients located overseas? If Yes, please provide details		Yes No

DIRECTORS, PARTNERS & PRINCIPALS DETAILS -

Section 3

Names	Qualifications	Date Qualified	Years in Position
			This Practice	Previous Practice
1
2
3
4
5


Staff Numbers	Full Time	Part Time
Directors, Partners, Principals
Professional Qualified Staff (not included above)
Other Technical Staff
Non Technical Staff
Trainee Staff
Administration Staff
Other Staff
Total Staff

FOR SOLE PRACTITIONERS / PROPRIETORS ONLY - [if not, proceed to Section 5]

Section4

Please provide details of the Proposer's Professional experience in this type of business.

Please provide details of the experience
of Senior Staff.

Please provide details of arrangements the Proposer has in place to ensure the business operates correctly during the Proprietor's temporary absences.

RISK MANAGEMENT PROGRAM -

Section 5

Does the Proposer have a documented Risk Management Program? If Yes, what Date was it implemented		Yes No

Is one Director - Partner - Principal responsible for the implementation and communication of the Program?		Yes No

Does the Risk Management Program include regular internel - external audits or reviews?		Yes No

Is the progam communicated to and available to all staff? If No, please provide details why not.		Yes No

FINANCIAL DETAILS-

Section 6

Please state the Total of Annual Gross Professional Fees for:

	Location	Previous Financial Year	Est Current Financial Year	Est Next Financial Year
a)	Australia	$	$	$
b)	Overseas (excluding North America)	$	$	$
c)	In North America	$	$	$
Total of a) b) and c) above		$	$	$

In reference to the Annual Gross Professonal Fees stated above, please provide the "percentage breakdown":

	Location	% of fee income	% of fee income
		Past 12 months	Est Next 12 Months
	NSW	%	%
	VIC	%	%
	QLD	%	%
	SA	%	%
	NT	%	%
	WA	%	%
	ACT	%	%
	TAS	%	%
	0/S	%	%
	TOTAL	%	%

Does any single client represent more than 35% of the Proposers's total business activities? If Yes, please provide details.		Yes No

Please provide details of the Proposer's 5 largest clients if together those clients account for more than 50% of the Proposer's Annual Income:


Name of Client	Income $AUD
	Past 12 mths	Est next 12 mths
1
2
3
4
5
TOTAL

CLAIMS HISTORY-

Section 7


After enquiry, have any claims for negligence or breach of professional duty been made against the Proposer or any of its Partners, Principals, or Directors.
	Yes No

	If Yes, give details below:-

Date of Claim or Loss	Brief Description of Claim	Cost of Claim $	Current Status of Claim

After enquiry, is the Proposer or any of its Partners, Principals or Directors aware of any circumstances which has the potential to give rise to a claim in relation to negligence or breach of professional duty.
	Yes No

	If Yes, give details below:-

Date First Notified	Brief Description of Claim	Name of Claimant	Potential Quantum $

After enquiry, is the Proposer or any of its Parners, Principals or Directors or staff subject to disciplinary proceedings for professional misconduct?
If Yes, please provide details

Yes No

PROPOSER'S INSURANCE HISTORY-

Section 8

Does the Proposer currently have professional indemnity insurance?

Yes No

If Yes, state:

Name of Insurer		Policy Number
Renewal Date		Limit of Indemnity $
Retroactive Date

Has any Insurer, in respect of professional indemnity insurance ever:-:

declined a proposal, refused renewal or terminated insurance?

Yes No

required an increased premium or imposed special conditions?

Yes No

declined an insurance claim by the proposer or reduced its liability to pay a claim in full (other than by application of an excess)?

Yes No