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Management & Risk Insurance Brokers
(M&R Insurance Brokers Pty Ltd)
175 Centre Road, Bentleigh Victoria 3204 Australia

Phone +61 (03) 9557 7400
Fax +61 (03) 9557 7355

Services
About us
- Who we are
- Charities & Community
Claims
Request a quote
Get in touch

Request a quote

Request quote (basic) updated

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General Information
Business Activities
Financial Details
Claims & Insurance History
Insurance Coverage Needed

Insured Name

Contact Name

Address

Unit & Street

City

State

Postcode

Phone Number

Website

Email

Date of Establishment

Australian Business Number (ABN)

Legal status

Sole Trader

Partnership

Private Company

Public Company

Other

Enter the legal status here

Number of Staff

Business Activities

Describe the nature of professional services provided in the percentage of work undertaken in:

Architect

%

Landscape Architecture

%

Drafting

%

Energy Rating

%

Interior Design

%

Project Management

%

Town / Master Planning

%

Access Consulting

Others

%

Total Split

Reminder: The total % of the activities needs to make up to 100%

Activities by State

The total % of the activities need to make up to 100%

ACT

%

NSW

%

NT

%

QLD

%

SA

%

TAS

%

VIC

%

WA

%

Overseas

%

Total Split

Reminder: The total % of the activities by state needs to make up to 100%

Financial Details

Total amount of gross fees or annual income:

Actual for the past 12 months

$

Estimated for the next 12 months

$

Claim & Insurance History

Has the entity, corporation, or any current or former director, partner, senior officer, or professionally qualified staff ever:

Incurred a claim for loss or damage arising from any of the risks now proposed for insurance?

Yes

No

Submitted a claim under this type of insurance policy?

Yes

No

Been refused this type of insurance, or had a similar policy cancelled?

Yes

No

Been subject to any complaint, disciplinary proceeding, or other inquiry regarding professional conduct?

Yes

No

Been convicted or fined for any offence, or been subject to a professional, trade, or business sanction (excluding traffic offences)?

Yes

No

Had a special condition applied to this type of insurance policy?

Yes

No

If you have answered YES to any of the above, please give a brief description:

Insurance Coverage Needed

Will this policy replace an existing policy?

Yes

No

Existing insurer

Expiry date of policy (if known)

What is the limit of liability you require? 1M, 2M, 5M, 10M other

Where did you hear from us?

Promo Code

I/We declare that the above statements are true and complete, and I/We agree that this proposal and any supplementary information shall form the basis of the contract with the insurer.

Signature

Name

Date

Mon - Fri | 8.30am - 5pm

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