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• Glenowar Pty. Ltd t/as Fenton Green & Co
  
  ABN: 14 074 776 631
  AFSL: 247258
  
  Phone: [phone]
  Fax: [phone]
  [e-mail]

Professional Indemnity and Public & Products Liability Application

Thank you for your quotation enquiry.

We look forward to assisting you with your insurance needs.

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Proposal Questions

1. Please list the activities or services for which cover is required?

2. Please list your association memberships? ('None' if not applicable)

Association: Member No:   

Claims and Circumstances

3.1 During the past 10 years has any Claim been made or has negligence been alleged, against any entity or individual to be insured by this insurance (including any prior corporate entity and any of the present or former Principals), or have any circumstances which may give rise to a claim against any of these been notified to insurers?

Yes No

3.2 Are there any circumstances not already notified to insurers that may give rise to a Claim against any entity or individual to be insured by this insurance (including any prior corporate entity and any of the present or former Principals)?

Yes No

3.3 Are there any Claims against previous practices which may give rise to a Claim against any entity or individual to be insured by this insurance (including any prior corporate entity and any of the present or former Principals)?

Yes No

3.4 Has any Principal or staff member ever been subject to disciplinary proceedings for professional misconduct?

Yes No

4. Please select the amount of cover required?

Professional Indemnity

$1,000,000

$2,000,000

$5,000,000

$10,000,000

$20,000,000

Public Liability

$5,000,000

$10,000,000

$20,000,000

5. Please advise gross turnover for the last 12 months?

6. Please advise staff numbers?

7. Please provide any further information relevant to your application?

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Insured Information

• Business Name

Agents / Instructors / Practitioners that cover is required for:

Insured: Please Select...MrMrsMissMsDrOther  

Postal Address
Town/City:
State/Territory/Province:	Please Select...ACTNSWNTQLDSATASVICWAOverseas
Post Code:
Country:	AustraliaNew ZealandChinaSingaporeSlovakiaSouth AfricaUnited KingdomIndiaHong KongUnited StatesMalaysiaPakistanIndonesiaUnited Arab EmiratesMacedoniaOther
Email:
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Telephone: