If you have spoken to a broker in our office, note their name here so that this quote can be processed by them as they will know something about you already.

Brokers Name:

Client Details

Insured Name

Trading Name

ABN No.(if known)

Full Address

Email Address

Website Address

Phone No. *

Do You require cover for any subsidiary or associated company?
Yes    No

If you answered "Yes" above, please give details.

Business Activity

What is your main occupation of the business?

Please give a description of your business activities.

Quote Required

Please nominate the amount of cover you require:

$500,000

$1,000,000

$2,000,000

$5,000,000

$10,000,000

Underwriting questions

Gross revenue for last 12 months

Gross revenue for previous 12 months

Total number of employees

Is the company planning any redundancies or retrenchments in the next 12 months?
Yes No

Please state the percentage of your turnover for each State

What percentage of your revenue is derived from Australia and/or New Zealand?
%

Does the business have operations or activities in the USA/Canada?
Yes No

General Information

Is any Director, Officer or Employee of the Company aware of any facts or circumstances that may affect the ability of the Company to meet its debts as and when they fall due or any change in the financial position or capital structure of the Company that may materially affect the performance of the Company?
Yes    No

Has any claim(s) been made against any Director, Officer or Employee of the Company for any matter that is or would be the subject of this insurance policy in the past 5 years where the value of all claims notified exceed $20,000 including current reserves, or is any Director, Officer or Employee of the Company aware of any circumstance or incident which may give rise to a claim under the policy?
Yes    No

Upon enquiry, has the Company ever had any loss sustained through the fraud or dishonesty of any employee?
Yes    No

Has your business, practice or any partner, principal or director ever been declined this type of insurance, or had similar insurance cancelled, or had an application for renewal declined, or had special terms or restrictions imposed?
Yes    No

Is the INSURED or COMPANY listed on the ASX or CHI X?
Yes    No

Declaration

By submitting this Declaration, I/we declare and agree that:

• I/we have the consent of all other persons covered by this policy to make this Declaration,
• the contents of this Declaration are true and complete,
• I/we have read the information concerning the duty of disclosure (immediately below this declaration) and other important notices;
• I/we have answered every question fully and frankly, have been truthful and accurate in completing this application and have not withheld any information likely to affect the acceptance of this insurance;
• I/we realise that if I/we have not complied with the duty of disclosure, any claims may not be met
• if anything happens during the Period of Cover which alters any of the information provided, I/we will promptly inform the insurer;
• I/we confirm that I/we have read and understood that this policy operates on a claims made and notified' basis; (refer - Claims Made Policy below)
• they authorise the insurer to give or obtain from other insurers or insurance reference bureaus or credit reporting agencies, any information about this insurance or any other insurance held by the Applicant/s.

Name of person making this declaration:

Duty of Disclosure - What you must tell us
Under the Insurance Contracts Act 1984 (the Act), you have a Duty of Disclosure. You are required before you enter into, renew, vary, extend or reinstate your Policy, to tell us everything you know and that a reasonable person in the circumstances could be expected to know, is a matter that is relevant to our decision whether to insure you, and anyone else to be insured under the Policy, and if so, on what terms.

• You do not have to tell us about any matter
• that diminishes the risk
• that is of common knowledge
• that we know or should know in the ordinary course of our business as an insurer, or
• which we indicate we do not want to know.
• If you do not tell us

Claims Made Policy
The Professional Indemnity section of this Policy operates on a 'Claims made and notified' basis. This means that the Policy covers you for Claims made against you and notified to us during the Period of Insurance.
This Policy does not provide cover in relation to:

• acts, errors or omissions actually or allegedly committed prior to the retroactive date of the Policy (if a date is specified);
• claims made after the expiry of the period of insurance even though the event giving rise to the Claim may have occurred during the period of insurance;
• claims notified or arising out of facts or circumstances notified (or which ought reasonably to have been notified) under any previous Policy;
• claims made, threatened or intimated against you prior to the commencement of the period of insurance;
• facts or circumstances of which you first became aware prior to the period of insurance, and which you knew or ought reasonably to have known had the potential to give rise to a Claim under this Policy;
• Claims arising out of circumstances noted on the proposal form for the current period of insurance or on any previous proposal form.