Professional Indemnity

Safeguard your business assets, operations, and liabilities with our tailored commercial insurance solutions, ensuring your enterprise stays protected.

APPLICATION & DECLARATION FOR PROFESSIONAL INDEMNITY INSURANCE

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Is Renewal

Insured Name*

NBN Number*

First Name*

Last Name*

Email*

Phone Number*

Advisors*

Total Staff*

External Cover*

Gross Income Last Year*

Estimated Gross This Year*

Please detail business activity & income split in dollar amount (If nil please show 0)

^{*must total to Estimated Gross}

Risk

Mortgage

Planning

KiwiSaver

Investments

DIMS**

Fire & General Referral***

Fire & General Placement***

Foreign Revenue*

Please advise total revenue from these clients.
_{Note: cover is provided for NZ domiciled advisers advising NZ citizens who are based overseas (excluding USA/Canada).}

Your Duty of Disclosure

Before you enter into this insurance you have a duty, at law, to disclose to us all material facts.This duty also applies when you renew, vary, extend or reinstate your policy.

A material fact is one that may influence a prudent insurer in deciding whether or not to accept the insurance and, if so, on what terms and conditions and for what premium.

Please read the duty of disclosure below and advise of any material facts (eg claims, convictions) need to be declared insert below:
Examples of information you may need to disclose include but are not limited to:

Anything that increases the risk of an insurance claim.
Subject to the Criminal Records (Clean Slate) Act 2004, any criminal conviction or offence.
If another insurer has cancelled or refused to insure or renew insurance, has imposed special terms, or refused any claim.
Any insurance claim made or loss suffered in the past.

_{These examples are a guide only. If there is any doubt as to whether a particular piece of information needs to be disclosed, this should be referred to Hutchison Rodway.}

If you fail to comply with the Duty of Disclosure, it may result in your claim being declined, the amount we pay if you make a claim being reduced or the contract being void from inception.

Declaration

On behalf of all proposed Policyholders I/We declare and agree that:

all information provided, in this renewal declaration or attachments, is true and complete in every respect and that no Material Facts remain undisclosed;
if this risk is accepted, such information will be incorporated into and form the basis of the contract of insurance;
I/We understand that the Insurer requires this information in order to evaluate this proposal and that the Privacy Act 2020 entitles me/us to have access to, and request the correction of, any information retained;
Hutchison Rodway Ltd are authorised to disclose information to the Insurer, reinsurers, other insurers and parties with a financial interest in the subject matter of this proposal;
The Insurer is authorised to check details against the Insurance Claims Register and to place information on the Insurance Claims Register which other insurers can access;
Hutchison Rodway Ltd on behalf of the Insurer are authorised to obtain from other parties any information which may be relevant to the acceptance of this risk;
the signing of this declaration does not bind either party to complete the contract and that no cover will be in force until confirmed by Hutchison Rodway Ltd and the Insurer.

*

I/We confirm that I/We have read the Duty of Disclosure and Declaration above and agree that by entering my name and clicking "Submit" I/We am electronically signing this Application. I /We confirm the appointment of Hutchison Rodway Ltd as our Insurance Brokers for PI and Liability insurance.

Thank you for your Application.

We'll be in touch within the hour after we have reviewed your submission.

Professional Indemnity

Account #1 - Name (Text)

APPLICATION & DECLARATION FOR PROFESSIONAL INDEMNITY INSURANCE

PI insurer

Appointment As Broker

Appoint us as Broker?

Insurance Details

Memberships

Please detail business activity & income split in dollar amount (If nil please show 0)

*must total to Estimated Gross

Your Duty of Disclosure

Declaration

Application #1 - PI

Created: 20/03/2025

Modified: -

Documents

Application Denial Form

Quote Form

Quote #1

Created: 20/03/2025

Modified: -

Documents

Quote Declination Form

Please let us know why

ACCEPTANCE FOR PROFESSIONAL INDEMNITY, COMBINED LIABILITY & CYBER INSURANCE

Coverage Option

Excess Option

Add Stylecover?

Add Cyber Liability Insurance?

Gross Income Revenue

Do you require Cyber Ultra optional Policy extension for Social Engineering Fraud

Is all personally identifiable and confidential information that is removed from your premises in any electronic format encrypted?

Do you regularly update (at least monthly) firewalls and virus protection software in place within your networks?

Do you have a Business Continuity Plan (BCP) which includes back-ups stored off-site, in place that is tested at least annually?

Do you have procedures for verifying destination bank accounts and/or any changes to destination bank account details, before funds are transferred?

Do you hold an approved list of vendors and suppliers, including authorised contact people and contact details, which is checked when payments are made?

Please identify your critical suppliers vendors

Claims & Circumstances

During the past 5 years has any claim been made, or have any circumstances which may give rise to a claim, against any entity or individual to be insured by this insurance been notified to insurers?

Are there any circumstances not already notified to insurers which may give rise to a claim against any entity or individual to be insured by this insurance?

Has any principal or staff member ever been subject to disciplinary proceedings, regulatory action, or investigation by any Government, regulatory or administrative agency?

please provide full details and refer to your Broker for further advice

Add Combined Liability Insurance?

Stand Alone Public Liability OR QPack?

We would like the option to pay our premium monthly (if taken will be subject to a finance charge)

Please confirm full details of Adviser names to appear on the Insurer cover confirmation Certificate

Declaration

Acceptance #1

Created: 20/03/2025

Modified: -

Documents

Thank you for Accepting Quadrant PI This Year.

We'll be in touch with Invoicing and Certificates Shortly.

Thanks For Your Feedback.

Hopefully Next Year We Can Do Better.

Policy Form

Names on Certificate

Policy #1

Created: 20/03/2025

Modified: -

Documents

Cancel Renewal Form

^{*must total to Estimated Gross}