Completing this online Proposal Form

Please answer all questions giving full and complete answers.
It is the duty of the proposer to provide all information that is requested in this Proposal Form as well as to disclose relevant facts. A relevant fact is a known fact or circumstances that may influence the evaluation of risk by the insurer. If you are uncertain about what a relevant fact is, please contact us.
If renewing an existing policy with Express Insurance, please ensure you check all information and make any necessary changes.

Business Details

Income Details

Total Annual Income

Occupation

Select your Occupation/s from the list below

Note this cover is designed to provide cover for an individual/singular practitioner

In respect of Total Annual Income, please provide a breakdown by State:

Total must be 100%:

NSW

ACT

QLD

VIC

TAS

Overseas

Are you a small business eligible for exemption from paying NSW stamp duty on certain types of Insurance?

Yes No

Period of Insurance

Policy Start Date

Promotional Code (if relevant)