Question 1: What state are you based in?*

Question 2: Do you currently use Insurance Advisernet as your insurance adviser?*

Yes No

Question 3: Do you perform any activities that are NOT listed below?*

Computer programming services
IT project management
Software and systems consulting
Analysis or design
Application software development
Systems integration
Value added reselling or installation

Maintenance or repair
Network consulting
Management or support services
Computer processing
Data preparation and processing services
IT training
IT testing or web design

Yes No

Question 4: In the next twelve (12) months are you planning to become involved with any new activities that represent a change in your operations or areas of concentration and which are NOT listed in question (3) above?*

Yes No

Question 5: Are any of your services or products included in the following?*

Medical Pharmaceutical or chemical industry applications
Oil, Gas/Power/Nuclear Energy applications and consulting
Defence Applications (excluding administration systems)
Aviation or Marine related applications
Fire, security or other emergency or other safety critical applications
Network security advice/products
Production Line or Manufacturing System (including SCADA or PLC) and process control systems
Enterprise Resource Planning (ERP)
Banking, stock, bond, commodity trading, or other financial trading systems
Manual work relating to underground cables and services

Yes No

Question 6: Are you involved with developing and licensing your own software products?*

Yes No

Question 7: Do you require insurance for any activities outside of Australia?*

Yes No

Question 8: Do you, or would you, ever negotiate with a customer or agency to provide services or products where there is not a signed written contract?*

Yes (Less than 20%) Yes (Over 20%) No

Question 9: Have you ever experienced any of the following*

Any contract disputes alleging non performance of product or service, including suits, potential suits or complaint letter
Any contract past due acceptance
Any customers who have withheld payments due to a contract dispute within the past three (3) years
Any dispute where you have been named that involve copyright, patent or trademark infringement
An insurance company decline to write Public Liability of Professional Indemnity Insurance for you

Yes No

Question 10: Are you aware of any act, error or omission, unresolved contract dispute or any other circumstance, which may reasonably be expected to result in a claim?*

Yes No

Question 11: In the past ten years have you or any insured person/business/corporation/director had any insurer decline any proposal from inception or declined any claim, cancelled or refused to renew a policy or imposed special conditions?*

Yes No

Question 12: In the past ten years have you or any insured person/business/corporation/director been convicted or had charges pending, for any criminal offence, including arson, or involving dishonesty of any kind?*

Yes No

Question 13: Have you ever had a non motor vehicle loss, whether insured or not, in excess of $20,000? If yes, provide details (acceptance will be required from the insurer/s)*

Yes No

Question 14: Do you authorise us to give to, or obtain from, other insurers or any reference service, any information relating to insurance held by you or any claim in relation thereto?*

Yes No

Question 15: Are you aware of any exceptional circumstances, not covered above, that would influence the underwriter's decision to accept the risk of insurance, or alter the terms? If yes, provide details (acceptance will be required from the insurer/s)?*

Yes No

Question 16: I have read and accept the privacy statement.*

I/we agree

Question 17: First Name*

Question 18: Last Name*

Question 19: Email*

Question 20: Phone*

Question 21: Address*

Question 22: Suburb*

Question 24: Postcode*

Question 25: Business Name*

Question 26: ABN* (e.g. 12 234 456 678)

Question 28: Income (Please select your closest, income range)*

Question 29: Cover Limit
(Please select the professional indemnity limit, please note your quotation will automatically include Public Liability (PI - Professional Indemnity, GL = General Liability))*

Premium:
Premium GST:
Stamp Duty:
Broker Fee:
Broker Fee GST:

Total:

(Excess: )

IT