Apply Online - Management Liability Plus

Policyholder*
Name of Company
Street Address*
Suburb*
Postcode*
Contact Number*
Website
Date Company Established*
Please describe the industry / business activities of the Company*
In the questions below a reference to a "Company" means the policy Holder and all of its Subsidiaries. Subsidiary means any entity recognised by law to be a Subsidiary or in which the Company holds more than 50% of issued capital or more than one half of voting rights at a general meeting of the Company
Is the Policy Holder a Subsidiary of another company?*
Please state the subsiduary company name in full

Insurance History
In the last 5 years have there been any claims made against the Company or its Directors which may have been covered under this policy if were in force?*
If Yes, please provide full details
Has any Director or Officer of the Company ever had proceedings (civil or criminal) instigated against them alleging misconduct or breaches of the law in their capacity as a Director or Officer of a Company*
If Yes, please provide full details
Has any Director or Officer of the Company ever been declared bankrupt or entered into a deed of assignment of scheme of agreement with creditors?*
If Yes, please provide full details*
In the last 5 years has the Company suffered any direct financial loss exceeding $5,000 as a result of fraud or dishonesty committed by a staff member?*
If Yes, please provide full details
Are any Directors or Employees of the Company aware of any facts which might give rise to a Claim being made against Company or its Directors?*
If Yes, please provide full details*
Are any Directors or Employees of the Company aware of any facts which would cause a reasonable person to think that the Company might suffer a direct financial loss as a result of Fraud or Dishonesty committed by a staff member?*
If Yes, please provide full details
Has an Insurer ever refused to insure, cancelled or refused to renew an insurance policy for the Company*
If Yes, please provide full details
Are you currently insured for Management Liability Insurance?*
Current Insurer
Please advise

Fidelity - Fraud prevention Controls
Does the company segregate duties so that no one individual can control any of the following activities from commencement to completion without referral to others?*
Tick all that are relevant
- Signing cheques, authorising payments or funds transfers above $5000
- Refund of monies or return of goods over $5000
- Reconciling bank statements
- Do you require a quotation for Fidelity Cover? ($50,000 limit)
- None of the Above
Would you like cover for claims arising out of the actual alleged insolvency of the Company?*
Please complete this question: Does the Company have financial statements that have been audited or reviewed by an external accountant in the last 12 months?*

Financial Information