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Personal Indemnity Form
Personal Indemnity Form
26/4/2024
The Insured
Insured Name:
*
Company Name/Trading Name:
*
Email Address:
*
Address:
*
Telephone:
*
Business Details
Business website address:
Please advise the state where Your main office is located
Please select...
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Date Your business commenced:
*
Do You conduct business in any overseas country?
Yes
No
Public Liability limit required:
10,000,000
20,000,000
Professional Liability limit required:
1,000,000
2,000,000
5,000,000
10,000,000
Other
Are You and Your employees (if applicable) a licensed real estate agent?
Yes
No
Are You involved in any property sales contracts over $20m in value?
Yes
No
Are any of Your principals, partners or directors financially or otherwise associated with any other business?
Yes
No
Please provide details of Your real estate agent activities by completing the table below :
REAL ESTATE AGENT ACTIVITIES
% (TOTAL MUST BE 100%)
Residential sales (not including "off the plan" sales):
*
0
Commercial / Industrial sales (not including "off the plan" sales):
*
0
"off the plan" sales - non CBD:
*
0
"off the plan" sales - CBD:
*
0
Rural sales:
*
0
Auctioneering:
*
0
Residential / Commercial / Industrial Property and Strata Management:
*
0
Property Development:
*
0
Mortgage / Finance Broking:
*
0
Project Management:
*
0
Insurance / Financial Institutions Agency:
*
0
Land / Business Broking:
*
0
Buyers Advocacy:
*
0
Valuations:
*
0
Other:
*
0
Do You manage any retail shopping centres or shopping malls or shopping complexes with more than 15 shops?
Yes
No
Do You have dual controls in place in respect to handling of monies or financial transactions?
Yes
No
Business History
Please provide Your turnover for last 12 months:
*
$
0
Have You currently got a Professional Indemnity policy in place?
Yes
No
Is Your current insurance policy with Guild (Acerta)?
Yes
No
During the past 3 years has the name of the Business changed, or has the Business acquired, merged or taken over any other firm(s), or been acquired, merged or taken over by any other firm(s),or is any acquisition, tender offer or merger pending or under consideration by the Business?
Yes
No
Has the Business ever had any Insurer decline a proposal, imposed any special terms, cancelled or refused to renew a
Professional indemnity insurance policy?
Yes
No
Have any claims/s been made against the business, its predecessors or against or any of its past or present principals, partners or directors?
Yes
No
Are You or any of Your principals, partners or directors after enquiry of all staff, managers and contractors, aware of any facts or circumstances which may give rise to a claim or claims against the business of the type covered under this policy?
Yes
No
Declaration
I/We declare no information has been withheld that would affect the acceptance of this insurance Proposal or the terms of that acceptance.
I/We agree that if any of the information given by us alters between the date of this Application and the inception date of the insurance cover to which the Application relates, I/We will provide immediate notice of any such alterations.
I/We agree to the use and disclosure of any of our personal information in accordance with the Privacy Statement contained in the Important Notices.
* Indicates a mandatory field.
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