Pest & Building Inspection Form

Contact Name: *
Email:
Phone Number

Legal Entity:
Trading Name *
ABN
Website:
Mailing Address
Number:
Street :
Suburb:
State:
Postcode:
Business Established

Estimated Turnover for the next 12 months
Actual turnover last 12 months
Turnover Split by State
NSW *
VIC
QLD
WA
SA
NT
ACT
TAS
Total

Note, a small business under the changes relating to the NSW Stamp Duty exemption defines that a business is a small business for an income year (the current year) if:

You carry on a business in the current year; and
One or both of the following applies:

  1. You carried on a business in the income year (the previous year) before the current year and the aggregated turnover for the previous year was less than $2m;
  2. The aggregated turnover for the current year is likely to be less than $2m.

For more information, visit: https://www.revenue.nsw.gov.au/taxes-duties-levies-royalties/insurance-duty/exemptions


Public Liability:
Professional indemnity :
Period of Insurance
From :
To:
Retroactive Date:
Professional Indemnity Retroactive Date (the date that you first had continuous Professional Indemnity cover, without any lapses in cover).
Expiry Date of Current Policy:

Select Activities





Total:
Number of Employees: *
(including directs and principals)

Please provide a breakdown of turnover split by the following locations.

Domestic / Residential
Commercial
Industrial
Agricultural
Farms
Total
Must Equal 100%
Is there any work undertaken at food manufacturing, grain silos, cool rooms, grain handling and other food preparations facilities?
If yes, please confirm where you conduct your activities (e.g. cafes, restaurants etc)
What safety precautions are undertaken?
Is there any work undertaken adjacent to any water course, dam, tailing dam and/or river?
If Yes, what safety precautions are undertaken?
Is there work undertaken refineries, chemical plant, petrol, oil or gas production facilities, offshore platforms/oil rigs, utilities, oil or gas pipelines, power stations, laboratories, water treatment plants, railway infrastructure, airports, underground work, dams, work on trains, watercraft or aircraft?
If Yes, what safety precautions are undertaken?

Only named principals, directors, employees and trainees will be covered by the insurance policy.
Name
Licence Type / Qualification
Licence Number
Expiry (if applicable)
Attach

Please note that in the event of a claim you may be asked to provide evidence of experience and qualifications.
Name
Building Inspections
Timber Pest Inspection
Termite Management

Does the proposer engage the use of subcontractors?
Estimated annual payments
Does the proposer enter into a written agreement with the subcontractor?
Activities undertaken by the subcontractor
Does the proposer request evidence of professional indemnity, public liability and workers compensation insurance?

Do all principals, directors, employees and trainees hold current relevant licences or certification to conduct the activities noted by you?
Does the proposer comply with the following in relation to the activities noted and undertaken by any person engaged by you?
1. Australian Standards
2. Industry Code of Practice
3. Statutory Regulations
Are the proposer's agreements and reports provided by a third party (i.e. Report Systems Australia)?
If yes which third party, if not have they been vetted by a legal practitioner
What software does the proposer use?
If you answered No to any of the questions in the Risk Management section, please provide details below

Has the proposer had any claims made against them (whether insured or not)?
Has any applicant ever been subject to disciplinary proceedings for professional misconduct?
Have any claims for negligence, professional negligence or breach of professional duty been made in the last 10 years?
Do any circumstances exist that might give rise to a claim against an applicant or any director, officer, employee or agent for negligence, professional negligence or breach of professional duty?
If Yes, please supply details below
Date of Loss, Description, Paid Status

After investigation, is the proposer or any principal, partner, or director aware :
of anyone having been charged with or convicted of any criminal offence (excluding traffic offences)?
of any insurance being declined or cancelled, application / proposal rejected, renewal refused, claim rejected, or special conditions or excess imposed by any insurer?
ever, either alone or jointly with others been declared bankrupt or subject to any form of insolvency administration (e.g. liquidation or receivership)?
If yes to any of the above, please provide details.

Professional Indemnity insurance policies operate on a 'Claims Made' basis. This means, the policy which responds is the policy in place at the time a claim is made against your practice or when you notify the insurer of circumstances that may give rise to a claim as opposed to when the work which is the subject of the claim was done.

Public and Products Liability can be issued on both a 'Claims Made' and 'Occurrence' basis.

This declaration must be completed and signed by or on behalf of the party applying for insurance.
The proposer/I/We

  1. declare that:
    1. the answers and information given by me/us in this Application are true and correct in all respects;
    2. no information has been withheld that would affect an insurers decision to accept this Application;
    3. where answers in this online application have not been competed by myself, they have been checked by me/us and I/we agree they are correct and true;
    4. I/we have read and understood the Financial Services Guide and Privacy Statement;
    5. if there was insufficient space to fully answer any questions, I/we have attached supplementary pages providing the additional information required.

  2. authorise Wallace Risk Solutions to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to these insurance covers, and any other insurances held by me/us and claims under those insurances.
Name