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Please read this important notice before completing this proposal form.
Management Liability Application
The information you provide will allow us to arrange a series of quotations options for you to review.
Step
1
of
5
20%
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?
*
Yes
No
Please state the subsiduary company name in full
Financial Information
Gross turnover for the current financial year (estimate)
*
Gross turnover for the prior financial year
*
Current valuation of total assets
*
Current valuation of total liabilities
*
Percentage of Income Generated By State:
VIC
NSW
QLD
SA
WA
NT
ACT
Overseas
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?
*
Yes
No
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
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
If Yes, please provide full details
Has an Insurer ever refused to insure, cancelled or refused to renew an insurance policy for the Company
*
Yes
No
If Yes, please provide full details
Are you currently insured for Management Liability Insurance?
*
Yes
No
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?
*
Yes
No
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?
*
Yes
No
Employment Practices Liability - Human Resources Management
Employment - please state number of staff
*
Full Time Personnel
Part-time, casual, trainees etc
*
Does the company use an application form as part of the employment process
*
Yes
No
Does the Company check references of potential employees and contractors?
*
Yes
No
Does the Company distribute employment handbooks/policies to all employees?
*
Yes
No
Does the Company have written workplace policies in relation to:
*
Please tick all that apply
The handling and resolution of complaints by employees
Termination of employment?
Discrimination?
Sexual harassment?
Equal opportunity?
None of the above
Declaration
I, the applicant declare that;
i) I am authorised by each of the Insured to sign this Proposal Form; and
ii) the above statements are correct, true and complete; and
(iii) no information material to this proposal form has been withheld; and
(iv) I understand that no insurance is in force until the insurer has confirmed acceptance
Your First Name
*
Your Last Name
*
Position
*
Contact Number
*
Email
*
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Comments
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