2. Details of the Association Is the association a subsidiary of another entity? What type of organisation is the association?
3. Activities and services of the association Please give full details of the activities of the association and its subsidiaries including all services provided to its members and to the public.
Please indicate if the association or its subsidiaries provide the following services: If Yes to any of the above, please provide details.
Does the association or its subsidiaries have a gaming licence? Does the association or its subsidiaries intend to change its activities? Does the association or its subsidiaries have any operations outside Australia other than the USA? Does the association or its subsidiaries have any operations in the USA?
Details of United States operations Details of number of employees employed by the association and its subsidiaries in the USA
Does the association or its subsidiaries have any manufacturing facilities in the USA?
4. Financial details Please state association’s and its subsidiaries consolidated turnover and assets as follows:
5. Directors’ and officers’ details Has any former or current director or officer of the association or its subsidiaries (current or past) ever been declared bankrupt? Please provide details of the name of director/ officer and the date declared bankrupt.
Has any former or current director or officer of the association or its subsidiaries (current or past) ever been a director or officer of an organisation placed in receivership, liquidation or provisional liquidation? Please provide details of the name of director/ officer and the date declared bankrupt.
6. Outside directorships Do any of the directors, officers or employees of the association or its subsidiaries hold or have they held (at the specific request of the association or its subsidiaries) any outside directorships or positions of equivalent status in any outside entities? Please provide the following details for each outside entity for which Outside Directorship cover is required and
attach the latest annual report for each outside entity.
If the latest annual report is not provided please note that an insolvency exclusion will apply in respect of that outside entity.
Details of any Directors and Officers Insurance provided by the Outside Entity
Details of any Directors and Officers Insurance provided by the Outside Entity
Details of any Directors and Officers Insurance provided by the Outside Entity
7. Trustees Is any director, officer or employee of the association or its subsidiaries currently a trustee or Policy Committee member of a corporate superannuation fund (excluding any industry, master or self managed superannuation fund) established for the benefit of employees of the association or its subsidiaries?
8. Mergers, acquisitions, and capital raisings Has the association or its subsidiaries undergone any corporate restructuring in the last 3 years? Does the Insured have any plans to acquire, sell, dispose of or merge with another association or business in the next 12 months? Is the Insured aware of any proposals relating to the takeover of the association or its subsidiaries by another association or business in the next 12 months?
9. Financial position Have the association's and its subsidiaries' financial statements been audited or reviewed by an external accountant in the last 12 months? Details of any Directors and Officers Insurance provided by the Outside Entity
To the best of the knowledge and belief of the association’s and its subsidiaries’ directors and officers, will the association and any subsidiaries and/or controlled entities be able to pay its/their debts as they fall due over the next twelve months?
10. Employment practices liability Are all employees engaged under a written employment contract? Are all employment contracts re-issued or subject to a formal letter of variation whenever there are changes to their terms? Does the association and its subsidiaries have a formal written termination of employment policy? Does the association and its subsidiaries have a formal written equal opportunity policy? Does the association and its subsidiaries have a formal written harassment policy incorporating an anti-sexual harassment policy? Does the Insured anticipate any redundancies, staff reductions or facility closures in the next 18 months?
11. Crime Is any individual authorised to do any of the following by themselves:
Issue a cheque or any other bank instruments or to authorise any payment in excess of $5,000? Process a refund to customers or accept any return of goods in excess of $5,000? Reconcile any bank account on which that individual is authorised to transact?
12. Tax Audit Tax audit covers fees incurred by the association and its subsidiaries in connection with an unforeseen audit of the association's or its subsidiaries' tax affairs by the ATO that are payable by the association to a tax adviser.
Do the association and its subsidiaries require tax audit cover? The Total Sum Insured that you require: Select more than one if you would like a quote on multiple limits
Have the association and its subsidiaries complied with all its statutory tax obligations? Have the association or its subsidiaries in the last five years, been the subject of an audit, inquiry or investigation relating to tax obligations or record keeping? Is there any reason to believe that the association or its subsidiaries will be the subject of an audit, inquiry or investigation relating to tax obligations or record keeping?
13. Statutory Liability The Statutory Liability Extension provides cover for the association and its subsidiaries for fines/penalties payable for Statutory offences.
Do you require the Statutory Liability Extension? Indicate the sub-limit required: Select more than one if you would like a quote on multiple limits
In the past five years have the association or its subsidiaries had any fine or penalty or infringement notice (other than for traffic offences) imposed by any Federal, State, Territory or local government or other regulatory authority? In the past five years have there been any incidents or circumstances which could give rise to a fine or penalty (other than for traffic offences) being imposed on the association or its subsidiaries by a Federal, State, Territory or local government or other regulatory authority?
14. Claims History For the purpose of answering this question, please note that reference to “association” includes all of its past and current subsidiaries.
Has any claim or allegation ever been made or civil, criminal or regulatory proceedings brought against the association or any director, officer or employee (whether as directors, officers or employees of the association or any other association), in respect of the risks of the kind to which this proposal form relates? Has any director, officer or employee ever received a notice to attend an official investigation, examination, inquiry or other proceedings ordered or commissioned by an official body or institution, in respect of the risks of the kind to which this proposal form relates? During the last 5 years has the association suffered any loss as a result of any dishonest or fraudulent or criminal act of any employee or any third party (including theft of stock, goods, property or money) in respect of the risks of the kind to which this proposal form relates? Please provide full details. If insufficient room please attach seperate sheet at bottom of form.
15. Known circumstances For the purpose of answering this question, please note that reference to “association” includes all of its past and current subsidiaries.
Give rise to a claim or lead to civil or criminal proceedings against the association or any director, officer or employee? Result in the association or any director, officer or employee being required to attend an official investigation, examination, inquiry or other proceedings? Give rise to a fine or penalty or infringement notice (other than for traffic offences) imposed by any Federal, State, Territory or local government or regulatory authority? Please provide full details. If insufficient room please attach seperate sheet at bottom of form.
It is agreed that if such facts, circumstances or situations exist, whether or not disclosed, any claim arising from them is excluded from this proposed coverage.
16. Current Insurance Does the Insured currently hold any Association Liability Insurance, or other insurance covering risks of the kind to which this proposal form relates?
Has any insurer, in respect of the risks to which this proposal form relates, ever (due to factors that related to the assessment of the particular risk):
Declined a proposal, refused renewal or terminated an insurance? Required an increased premium or imposed special conditions? declined an insurance claim by the Insured or reduced its liability to pay an insurance claim in full (other than by application of an Excess)? 17. Limit of Liability If you would like a quote on multiple limits please select more than one
The Total Sum Insured that you require: Select more than one if you would like a quote on multiple limits
18. Stamp Duty Please provide a breakdown in the number of employees by location as follows.
DECLARATION TO CLAIM THE NSW DUTIES ACT 1997 SMALL BUSINESS STAMP DUTY EXEMPTION: To claim NSW Stamp Duty Exemption agree to declaration below.
I declare that at the time the above policies are effected or renewed, I am/will be a “small business” as defined insection 259A of the Duties Act 1997 (NSW): Servicer allied amank angelak angelom annep ashleem ashleighf brads chloed daniellek davidl davidw derekb dorat duncanb elizaw emmap erinr evanp frankm glenysj gregh jackt jessicag josies junaidq karlas kates kerryt kristini kurts lisah malcolmh marcw mathewn mattc mattk mellissab michelleg niad NickF nicolen paulap paulz phillipo reneeg richarda salmank saram susanj terrij tiffanyl toms travisr vincentr wadec
19. Additional Documents & Comments Please attach a copy of your CV and any additional company information you feel may assist us in understanding your professional business practice
Any additional document/s you wish to provide (up to 2mb pdf & jpg allowed)
Any additional information you wish to provide
17. DECLARATION I/We hereby declare that:
My/Our attention has been drawn to the Important Notice accompanying this Proposal form and further I/we have read these notices carefully and acknowledge my/our understanding of their content by my/our signature/s below.
The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this Proposal form and the inception date of the insurance to which this Proposal relates I/we shall give immediately notice thereof.
I/We authorise Austbrokers Countrywide to collect or disclose any personal information relating to this insurance to/from any other insurers or insurance reference service. Where I/We have provided information about another individual (for example, an employee, or client),
I/We declare that the individual has been or will be made aware of that fact and the section in the Policy on “The way we handle your personal information”.
I/We also confirm that the undersigned is/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this Proposal form and I/we complete this Proposal form on their behalf.
I/We declare that where we declare our turnover less than $2million that I/we are a small business eligible for the exemption from the requirement to pay duty on certain types of insurance under section 259B of the Duties Act 1997 (NSW).
You must agree to the form to proceed* Agreeing to the form does not bind the practice or Insurers to complete the insurance.
To be signed by the Chairman/President/Managing Partner/Managing Director/Principal of the association/ partnership/company/practice/business.
It is important that the signatories to the Declaration are fully aware of the scope of this insurance so that all questions can be answered. If in doubt, please contact us since non-disclosure may affect an Insured’s right of recovery under the policy or lead to it being voided.
Time Stamp 06/06/2023
Admin Details Servicer* allied amank angelak angelom annep ashleem ashleighf brads chloed daniellek davidl davidw derekb dorat duncanb elizaw emmap erinr evanp frankm glenysj gregh jackt jessicag josies junaidq karlas kates kerryt kristini kurts lisah malcolmh marcw mathewn mattc mattk mellissab michelleg niad NickF nicolen paulap paulz phillipo reneeg richarda salmank saram susanj terrij tiffanyl toms travisr vincentr wadec
Transaction* Create MFiles Lead Do not create MFiles Lead Renewal
