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PROFESSIONAL INDEMNITY FORM

General Information
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After investigation are you or any principal, director or partner aware of:

Please provide us with a breakdown of your gross income/fees for your business/profession.

Please provide us with a breakdown of your gross income/fees for your business/profession.

Please advise details of the 3 largest projects below for the last financial year. Ensure you include a project description, fees/income, project value and date of completion.

Declaration

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

a) declare that:

i. the answers and information given by me/us in this Application are true and correct in all respects;

ii. no information has been withheld that would affect an insurers decision to accept this Application;

iii. 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;

iv. I/we have read and understood the Financial Services Guide and Privacy Statement

v. if there was insufficient space to fully answer any questions, I/we have attached supplementary pages providing the additional information required.

b) authorise Wallace Risk Solutions Pty Ltd 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.

Files must be less than 2 MB.
Allowed file types: gif jpg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.