Application Form and Insurance Information

Transcription

1 Application Form and Insurance Information Family Day Care Australia Educator Insurance 9

2 Insurance Application Form C A O OFFICE USE ONLY Applicant Details Name of family day care coordination unit you are registered with: Your title: First name: Last name: Address: Suburb: State: Postcode: Date of birth: Phone: (home) Phone: (mobile) Fax: Have you ever held public liability insurance for your family day care service with a different insurer? If YES, which insurer: Period of continuous cover: to Agents Authority: an agent is a person you authorise to act on your behalf. I authorise (agents name) to act as my agent in relation to my FDC business insurances. Agent s signature: Agent s date of birth: I understand that I can withdraw my consent to the use of my personal information for the purposes of receiving marketing and promotional materials at any time by contacting Family Day Care Australia on freecall Your membership package refer to pages 4-6 for package information and pricing. Tick your selected option. Family day care (and FDC + IHC) Out of home care (FDC + OOHC) In home care (only) 12 month policy 3 month kick start* 12 month policy 3 month kick start* 12 month policy 3 month kick start* *A kick start package can only ever be used once by an educator. If you would prefer a customised package or non member rate contact FDCA on NB: FDCA members receive significant discounts on premiums and individual products do incur a surcharge. Policy start date please commence my policy on Select the date of your first schedule parent interview or, the expiry date of your existing policy. If we receive this application form after that date we will back date your policy to the specified date, as long as it is within 30 days and there have been no incidents during that time. Duty of Disclosure and Declaration I declare that a) I have read and understood Family Day Care Australia s Financial Services Guide, Privacy Policy, Duty of Disclosure and Product Disclosure Statement for Personal Accident Insurance for Children, if this product has been selected. b) I have read and understood the Direct Debit Conditions and, should I choose to pay by instalment I agree to be bound by those Conditions. C) I authorise Family Day Care Australia to give to or obtain from any relevant authority, any information relating to my insurances. Before you enter into a general insurance with an insurer, you have a duty under the Insurance Contracts Act 1984, to disclose to the insurer every matter which you know, or could reasonably be expected to know, is relevant to the insurer s decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to the insurer before you renew, vary or reinstate a contract of general insurance, Your duty however does not require disclosure of any matter: that diminishes the risk to be undertaken by the insurer, that is of common knowledge, that your insurer knows, or in the course of his business, ought to know and as to which compliance to your duty is waived by the insurer. The questions below are a mandatory requirement of your application. They must be answered. If yes please provide details on an attached sheet. 1. Has any insurer ever cancelled, declined or refused to renew or imposed special conditions on any of your insurances? 2. During the last 5 years have any claims been made or threatened against you that might have been insured under the insurance policies you are applying for? 3. Are you aware of any circumstances which have already occurred that might result in a claim under the insurance policies you are applying for or are you aware of any impending infringement notice or fine under the Education and Care Services National Law or any other relevant Act? Declaration signature Date Return by post, fax or Post: PO BOX 571, Gosford NSW 2250 Fax: memberservices@fdca.com.au Family Day Care Australia ABN AFSL Family Day Care Australia Educator Insurance 13

3 Insurance Payment Options If you have selected a Kick Start Package you must pay the full amount (you cannot pay by instalments). The amount you will be charged will be based on the package you have selected and in line with the Package Pricing Chart on page 8 of this booklet. The annual full payment option is a one off payment of the premium due. The monthly instalments option is a business loan agreement between you and the Premium Funder. The loan is repaid over 10 monthly instalments and includes additional administration fees. How would you like to pay? Annual full payment Select your payment option. Monthly instalments 1. Credit Card We will debit your selected package fee from the nominated credit card. Complete and return this form. Card Type: MasterCard Visa Name of Cardholder Card Number Expiry Date CVV *What s this? Signature Date Signed *CVV is the 3-digit code on the back of your card OR 2. Bank Account Direct Debit We will debit your selected package fee from the nominated account. Complete and return this form. Name of bank Branch Branch Number (BSB) Name of account holder Account number Signature Date Signed OR 3. Cheque or Money Order tick the box below and return this form by post with your chequemoney order. Enclosed is a chequemoney order made payable to Family Day Care Australia. OR 4. Phone If paying by phone you do not need to complete this form. Contact Family Day Care Australia on Return by post, fax or Post: PO BOX 571, Gosford NSW 2250 Fax: memberservices@fdca.com.au Family Day Care Australia ABN AFSL Family Day Care Australia Educator Insurance 11

4 Insurance Payment Options Back 12 Family Day Care Australia Educator Insurance

5 Financial Services Guide September 2014 (V17) This Financial Services Guide (FSG) contains important information to assist you in deciding whether to use our services and includes: business ought to know, as which compliance with your duty is waived by the insurer. 1. Who we are and who we act for n-disclosure and Misrepresentation 2. Types of services we provide If you fail to disclose any matter, which you were under a duty to disclose to the insurer or you made a misrepresentation to the insurer before this Policy was entered into, the Insurer may be entitled to reduce its liability under the Contract in respect of a claim or may cancel the contract. If your non disclosure is fraudulent, the Insurer may also have the option of voiding the contract from its beginning. Contracts of Insurance are subject to the doctrine of utmost good faith. Failure to adhere to this may prejudice any claim. 3. Your Duty of disclosure 4. Product Disclosure Statement (PDS) 5. Insuring the interest of other parties 6. Change of risk or circumstances 7. Terms of the insurance contract 8. Insurers rights following a claim 9. Insurers 10. Access to your information 11. Payment for our services 12. Cooling off period 4. Product Disclosure Statement If you ask us to arrange personal accident insurance for carers or children, motor vehicle or home and contents insurance we will provide you with a Product Disclosure Statement (PDS) unless you already have an up to date version. It is prepared by the insurer and is designed to help you make an informed decision about the financial product. 5. Insuring the interest of other parties 14. Complaints policy If you require the interest of a party other than the named insured to be covered, you MUST request this. Most Policy conditions will exclude indemnity to other parties. 15. Insurance Brokers Code of Practice 6. Change of risk or circumstances 16. Compensation arrangements for clients losses It is important that you advise us of any location changes, business activities or any departure from your normal form of business. 13. Potential conflicts of interest 17. How to contact us 7. Terms of the insurance contract 1. Who we are and who we act for By taking out this insurance you agree that: Family Day Care Australia Limited (FDCA) ABN AFSL is the national association for family day care. As an insurance broker we act on your behalf. a) FDCA has appointed Imalia CareCover Pty Ltd (Imalia CareCover) to act as our authorised representative (AR ). Imalia CareCover acts on behalf of FDCA, and therefore also acts on your behalf. b) You have read and understood the Premium Funding Payment and Instalment Plan Terms and Conditions and you agree to be bound by these Terms and Conditions. 2. Types of services we provide c) You authorise FDCA (ABN ) to give to or obtain from any relevant authority any information relating to the status of the insurances you have selected. We can provide general product advice and arrange general insurance products. Imalia CareCover is authorised to provide general advice on, and (deal) in, Public Liability Insurance, Management Liability Insurance, Personal Accident Insurance for Children and Carers, Property and Motor Insurance. Imalia CareCover carries out the day to day policy administration and management activities on behalf of FDCA. Any advice we provide is general in nature and we do not take into account your personal needs or financial objectives. Before you decide to purchase general insurance products from us you need to consider if the advice and relevant product is right for your circumstances as we have not done this. We act as a referrer only for Income Protection and Superannuation. In making any referral we do not advise or represent that their products and services are right for you and take no responsibility for the products and services they may provide to you. You need to make your own decision based on the information they provide. Premium funding is available for certain FDCA products and enables you to spread your payment over instalments rather than pay it in a lump sum; however you will have to pay a fee to the premium funder. When we offer you premium funding we act on behalf of the premium funder, not you. We do not provide personal advice or represent that any of the funder s products and services are right for you or that they are the most appropriate. You need to make your own decision based on the information provided. 3. Your Duty of disclosure Before you enter into a contract of general insurance with an Insurer, you have a duty under the Insurance Contracts Act 1984, to disclose to the Insurer every matter that you know, or could reasonably be expected to know, is relevant to the Insurer s decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to the Insurer before you renew, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of any matter that diminishes the risk to be undertaken by the Insurer, that is of common knowledge, that your insurer knows or, in the course of their You have read and understood FDCA s Financial Services Guide and Duty of Disclosure, Privacy Policy and the relevant Product Disclosure Statements if Personal Accident for Children or Carers, Motor Vehicle and Home & Contents insurances have been selected. d) You understand that: i) any statement made in the application will be treated by us as a statement made by all the people insured ii) the insurances and membership are only valid if you are registered with an Australian Government Funded Family Day Care scheme or In-Home Care service e) If you are a FDCA member, you agree to be bound by the constitution and by-laws of FDCA f) The insurances and membership are non-transferable 8. Insurer s rights following a claim Under the policy the insurer is entitled on the happening of any accident, injury, loss or damage to undertake in your name and on your behalf the conduct, control and settlement of any proceedings and to take proceedings at their own expense and for their own benefit but in your name to recover property or secure indemnity or contribution in respect of anything insured in this Policy. 9. Insurers Your Insurances are only arranged with Insurers that are authorised under the Insurance Act 1973 to conduct insurance business in Australia. Although the insurers are subject to the supervision of the Australian Prudential Regulation Authority (APRA), we are not in a position to guarantee that any insurer will at all times be in a position to pay claims as and when they occur and we disclaim any liability for losses that you may not be able to recover from your insurers. Family Day Care Australia Educator Insurance 13

6 10. Privacy We are committed to protecting your privacy. We use the information you provide to advise about and assist with your insurance needs. We provide your information to insurance companies and agents that provide insurance quotes and offer insurance terms to you or the companies that deal with your insurance claim (such as loss assessors and claims administrators) as well as contractors or partners who supply services to us or our members. Your information may be given to an overseas insurer (like Lloyd s of London) if we are seeking insurance terms from an overseas insurer or to reinsurers who are located overseas. We will try to tell you where those companies are located at the time of advising you and if necessary, seek your consent before disclosing your information to them. We do not trade, rent or sell your information. If you don t provide us with full information, we can t properly advise you, seek insurance terms for you or assist with claims and you can breach your duty of disclosure. For more information about how to access the personal information we hold about you, how to have the information corrected and how to complain if you think we have breached the privacy law, ask us for a copy of our Privacy Policy or visit our website. 11. Payment for our services When we place insurance for you we receive commission from the insurer (including renewals and some variations to the policy). The commission is a percentage of the insurer s base premium (i.e. excluding stamp duty, fire services levy, GST or any other government charges, taxes, fees or levies). The commission rate varies between 0-30%. Different insurers can agree to pay us different commission rates for the same type of products. The rates also vary for each product type. FDCA may sometimes receive additional remuneration from insurers though profit commissions on insurance products. Because the amount of the commission earned may vary depending on the performance of the portfolio over a period of time, the amount of possible commission attributable to any policy will not be known at the time of placement. FDCA pays to Imalia CareCover a fee equal to 35% of the commission we receive for the policy administration and management services it provides to us. We receive between 0-30% commission from Income Protection and Superannuation referrals. The commission does not represent our profit margin as it also reimburses us for administrative and other expenses we incur in providing our services. The commission is included in the premium amount detailed on your invoice and we receive it when you pay the premium or at a later time as agreed with the insurer. You may cancel your policy at any time and under certain circumstances, you may be eligible for a refund. If you advise us in writing within 14 days of the inception date of the policy and no care has taken place, we will refund the full premiums of certain products less a cancellation fee of $ Beyond this 14 day term, Membership, Telephone Legal Advice, Personal Accident for Children and Kick Start Packages are non refundable. A proportion of your Public Liability Insurance may be eligible for refund beyond the 14 day term, less fees, commissions and government charges. refunds are available on the Educator Management Liability Insurance Policy. We also have standard administrationpolicy handling fees which are charged in addition to the premium for the insurance to cover the cost of services for preparation and distribution of FDCA documentation and other services we provide to our members. The FDCA fee ranges between $0-$300 per policy and is noted in the documentation we send you. They are non-refundable. If you pay annually and cancel or vary your insurance package mid-term, FDCA will retain $25 (including GST) for our expenses in relation to the cancellation andor variation. If we have an agreement from you to direct debit your account and the agreed payment dishonours, we will charge you $30 (including GST) for our expenses in relation to the dishonour. If you are not a member of FDCA we will charge you a non-member fee of $ to arrange your insurance packages. From time to time FDCA provide sponsorship andor financial support to various Associations and co-ordination units of up to 10% of the annual premium. 12. Cooling off period A cooling off period may apply to an insurance policy issued to you as a retail client. During the period you may return the policy. If a cooling off period applies to your policy the details of your rights are included in the relevant Product Disclosure Statement. 13. Potential Conflicts of Interest FDCA and its staff may also receive soft dollar benefits from insurers and other service providers and can include entertainment or small gifts. There are no other associations or relationships with insurers which may influence us in providing our services. 14. Complaints Policy FDCA have developed a Complaints and Dispute Resolution Process which is fair, efficient and accessible to all our clients. If you would like to make a complaint about the services provided by FDCA or Imalia Care Cover you should telephone FDCA on free call , or if you wish you can put your complaint in writing for referral to the complaints officer. The complaints officer will acknowledge your complaint in writing as soon as it is received by FDCA. We will respond to your complaint within 5 business days of receipt by FDCA. If the complaint is not resolved to your satisfaction you can refer the matter to the Financial Ombudsman Service Limited (FOS) which is a national scheme for consumers. Its aim is to resolve disputes between clients, brokers and insurance companies. Contact them at Financial Ombudsman Service Limited GPO Box 3, Melbourne VIC 3001 Telephone: E: info@fos.org.au 15. Insurance Brokers Code of Practice FDCA subscribes to the National Insurance Brokers Association Code of Practice (The Code). The code sets out standards for Brokers to follow when dealing with clients. The code is available at Compensation arrangements for clients losses FDCA has a professional indemnity insurance policy (PI policy) in place. The PI policy covers FDCA, Imalia CareCover and their representatives (including ex employees and representatives) for claims made against them by clients as a result of their conduct in the provision of financial services. 17. How to contact us Family Day Care Australia Limited PO Box 571, Gosford NSW 2250 Telephone: Fax: E: memberservices@fdca.com.au W: This FSG Version was prepared on 1 September 2014 by Family Day Care Australia Limited ABN: , AFSL : Please keep this document for your reference and any future dealings with us. All commission and fees assist to support the work of FDCA. When you pay us your premium it will be banked into our trust account. We retain the commission from the premium you pay us and remit the balance to the insurer. We may earn interest on the premium while it is in our trust account and retain any interest earned on the premium. If we arrange premium funding for you we are paid a commission of between 0-3% of the funded premium. 14 Family Day Care Australia Educator Insurance

7 Product Disclosure Statement (PDS) Group Personal Accident Policy - FDCA Personal Accident Insurance for Children Accident & Health International Underwriting Pty Limited, ABN , AFS Licence no , is an underwriting agency specifically created to provide Personal Accident, Medical and Travel insurance. They have been in operation since March 1998 and act on behalf of CGU Insurance Limited, ABN , AFS Licence no , with full authority to quote and issue contracts of insurance, collect premiums and pay claims. If you have any queries about this policy you should contact A & H International. Their contact details are in this document. The Insurer The Insurer of the Policy is CGU Insurance Limited. What is a Product Disclosure Statement This Product Disclosure Statement (PDS) contains information about the policy including the benefits and conditions, your rights as a client and other things you need to know to assist you to make an informed decision when choosing your insurance. In this PDS: we, our or us means CGU Insurance Limited; you means the person who will be named in the policy schedule as the insured and any person nominated by you from time toy time for the insurance cover selected by you and for which the premium has been paid. The type of cover chosen will be set out on the policy schedule. Key Features of the Policy We will pay you up to $10,000 for Death & Capital Benefits and $2,000 towards incidental expenses and n-medicare costs incurred by a child in your care or the child s family for a claim resulting from an accident during the currency of the policy. The accident must occur to a child while under the care of a registered Family Day Care or In-Home carer, and the expenses must arise within twelve (12) calendar months from the date of the accident. The Most We Will Pay The most we will pay for all claims under this Policy during any period of insurance is set out under the Limit of Liability in the policy schedule. Once the Limit of Liability has been paid, you will need to pay us further premium to reinstate the policy cover. What You Are t Covered For There are certain times when there is no cover under the Group Personal Accident policy which means we may refuse to pay your claim. Specific Exclusions are listed in the Policy Wording. The Cost of Your Policy and Paying For Your Insurance The cost of your policy will be shown on the quotation provided, once all required information has been received. The cost of your policy is calculated based on number of persons involved, claims experience and other information relative to the particular risk. The cost of the policy is made up of premium, government taxes such as Goods & Services Tax (GST) and stamp duty, where applicable and fees. Your Duty of Disclosure When you apply for insurance you need to tell us certain information which would affect our decision to insure you. If you do not give us this information it may affect your policy. The duty of disclosure appears in full below; please ensure you read this duty. The duty of disclosure notice will also appear on your renewal invitation and the duty of disclosure also applies to any endorsements or variations you ask for. Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contracts Act 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer s decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of matter: that diminishes the risk to be undertaken by the insurer; that is of common knowledge; that your insurer knows or, in the ordinary course of his business, ought to know; as to which compliance with your duty is waived by the insurer. n disclosure If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce his liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning. Making A Claim and Your Franchise Amount A franchise amount applies if you make a claim under this policy. A franchise means that any claims under the franchise amount will not be paid, but if the claim is greater than the franchise amount, the entire claim will be paid. The franchise amount is stated in the Schedule. If you need to make a claim please send a written notice of claim to A & H International within 30 days of the date of the Injury occurring. A & H International will send you a copy of their claim form which will need to be fully completed. We will not be responsible for any payments under the policy unless this form is fully completed and returned. Any costs involved in the collection of information for the form are your responsibility. Cooling-Off If you decide that you do not want the policy, you have a cooling off period of 21 days from the date the policy was issued to cancel the policy. You must tell us in writing that you wish to cancel the policy and we will repay the full amount of premium to you. You cannot use this cooling-off period if the policy has already expired or if you have made a claim under it. Dispute Resolution We and A & H International will do everything possible to provide a quality service to you. If you have any concern or complaint A & H International staff are always available to listen to you and to help where they can. If, after talking to a staff member, you wish to take the matter further, A & H International has a Complaints and Dispute Resolution Procedure which undertakes to provide an answer to you within fifteen (15) working days. Please contact the Disputes Resolution Manager see contact details in this Product Disclosure Statement. If you are not happy with any decision and it relates to a claim, you may take your complaint to the Financial Ombudsman Service Limited (FOS), an independent and external dispute resolution body subject to eligibility. Access to the FOS process is free of charge to you. Please contact A & H International if you would like further information about the FOS or contact: Financial Ombudsman Service Limited; GPO Box 3. Melbourne VIC Telephone: info@fos.org.au. Web: Privacy We are committed to protecting your privacy. We use the information you provide us to quote on your application for a policy, to provide the insurance, administer the policy and assess and manage any claims. We only provide personal information to our underwriters and reinsurers (and their representatives) and those we appoint to assist us with claims under your policy. If you do not provide us with full information, we cannot properly quote for your insurance and we cannot insure you. You can check the personal information we hold about you at any time. Such application should be directed to A & H International in writing where it will be considered by their internal Privacy Disputes Department. If you provide us with personal information about anyone else, we rely on you to have their consent if you will be providing their information to us, and that you have told them to whom we may provide it, the purposes for which we will use it and that they can access it. If the information is sensitive, we rely on you to have obtained their consent on these matters. For more information about our Privacy Policy, please visit our website to obtain a copy: Contact Details Accident & Health International Underwriting Pty Limited ABN AFS Licence : Level 4, 33 York Street SYDNEY NSW 2000 Telephone: (02) Fax: (02) Website: enquiries@acchealth.com.au The Insurer CGU Insurance Limited ABN AFS Licence : George Street SYDNEY NSW 2000 Telephone: Website: This Product Disclosure Statement was prepared on 1st vember A&H International are authorised to distribute this Product Disclosure Statement. Family Day Care Australia Educator Insurance 15