professional indemnity insurance proposal form

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1 professiona indemnity insurance proposa form Important Facts Reating To This Proposa Form You shoud read the foowing advice before proceeding to compete this proposa form. Duty of Discosure Before you enter into a contract of genera insurance with an insurer, you have a duty, under the Insurance Contracts Act 1984, to discose to the insurer every matter that you know, or coud reasonaby be expected to know, is reevant to the insurer s decision whether to accept the risk of insurance, and if so, on what terms. You have the same duty to discose those matters to the insurer before you renew, extend, vary or reinstate a contract of genera insurance. Your duty, however, does not require discosure of any matter: that diminishes the risk to be undertaken by the insurer; that is of common knowedge; that your insurer knows or, in the ordinary course of his business, ought to know; as to which compiance with your duty is waived by the insurer. Non-discosure If you fai to compy with your duty of discosure, the insurer may be entited to reduce its iabiity under the contract in respect of a caim, refuse to pay the caim or may cance the contract. If your non-discosure is frauduent, the insurer may aso have the option of avoiding the contract from its beginning. Caims Made and Notified Basis of Coverage The Professiona Indemnity Insurance Poicy is issued on a Caims made and Notified basis. This means that the Insuring Cause responds to: a) caims first made against you during the poicy period and notified to the insurer during the poicy period, provided that you were not aware at any time prior to the poicy inception of circumstances which woud have put a reasonabe person in your position on notice that a caim may be made against him/her; and b) written notification of facts pursuant to section 40(3) of the Insurance Contracts Act The facts that you may decide to notify, are those which might give rise to a caim against you. Such notification must be given as soon as reasonaby practicabe after you become aware of the facts and prior to the expiry of the poicy period. If you give written notification of facts the poicy wi respond even though a caim arising from those facts is made against you after the poicy has expired. For your information, section 40(3) of the Insurance Contracts Act 1984 is set out beow: S40(3) Where the insured gave notice in writing to the insurer of facts that might give rise to a caim against the insured as soon as was reasonaby practicabe after the insured became aware of those facts but before the insurance cover provided by the contract expired, the insurer is not reieved of iabiity under the contract in respect of the caim when made by reason ony that it was made after the expiration of the period of the insurance cover provided by the contract. When the poicy period expires, no new notification of facts can be made on the expired poicy even though the event giving rise to the caim against you may have occurred during the poicy period. Retroactive Date You wi not be entited to indemnity under your new poicy in respect of any caim resuting from an act, error or omission occurring or committed by you prior to the retroactive date, where one is specified in the poicy terms offered to you. Subrogation Waiver Our poicy contains a provision that has the effect of excuding or imiting our iabiity in respect of a iabiity incurred soey by reason of the Insured entering into a deed or agreement excuding, imiting or deaying the ega rights of recovery against another. Privacy Statement The Privacy Act 1988 (Cth) (as amended) requires us to inform you that: Purpose of coection We coect persona information (this is information or an opinion about an individua whose identity is apparent or can reasonaby be ascertained and which reates to a natura iving person) from or about you, for the purposes of: identifying you when you do business with us; estabishing your requirements and providing you with the appropriate product or service incuding evauating your appication for insurance and any request for amendment to any insurance provided; setting up, issuing, administering and managing the insurance provided foowing acceptance of an appication; Insurer: Vero Profin, is a division of Vero Insurance Limited ABN V /06/09 B Page 1 of 8

2 assessing and investigating and, if covered, managing caims made in reation to any insurance you have with us or other companies within the Suncorp group; and understanding your needs and improving our financia products and services, incuding training and deveoping our staff and representatives. We may use and discose your persona information for a secondary purpose reated to those purposes isted above, where you woud reasonaby expect us to sue or discose your persona information for that secondary purpose. In the case of sensitive information, any secondary purpose, use or discosure wi be directy reated to the purposes isted above. Discosure When necessary and in connection with the purposes isted above, we may discose your persona information to, and/or receive some persona information from: other companies within the Suncorp group; intermediaries incuding your agent, adviser, a broker, a representative acting on your behaf, other Austraian Financia Services Licensees or our authorised representatives and our agents; government bodies, aw enforcement or statutory bodies, other insurance companies, reinsurers, financia institutions, insurance and caims reference providers, credit agencies, oss assessors, financiers or investigative service providers; maiing houses, customer research organisations; ega and other professiona advisers; and other service providers, hospitas, medica and heath professionas. Marketing purposes We woud ike to use and discose your persona information to keep you up to date with the range of products and services avaiabe from Suncorp. Generay, our companies in the Suncorp group wi use and discose your persona information for Suncorp s marketing purposes. We may aso use your persona information for the purpose of marketing other products and services of third parties we think may be of interest to you. If you do not want us to use and discose your persona information for the purpose of marketing products and services to you, you shoud contact us and te us. Pease contact us on the detais provided on the ast page of this Proposa Form. Discosure of persona information overseas Our business is trans-tasman and therefore we wi have instances where for the purposes detaied above we may send your persona information to other companies in Suncorp who are in either in Austraia or New Zeaand. There are aso other instances where we may have to send your persona information overseas or coect persona information from overseas. These instances incude: when you have asked us to do so; when we are authorised or required by aw to do so; when we have outsourced a business activity or function to an overseas service provider with whom we have a contractua arrangement; certain eectronic transactions; or it is necessary in order to faciitate a transaction on your behaf. Consequences if information is not provided If you do not provide us with the information we need we wi be unabe to administer your poicy or manage any caim under your poicy. Access You can request access to the persona information we hod about you by contacting a Vero office at one of the addresses shown on the ast page of this Proposa Form. In some circumstances we are abe to deny your request to your persona information, such as when it is unawfu to give it to you. If we deny your request for access, we wi te you why. Privacy Statement Issued Vero Insurance Limited registered office Leve 18, 36 Wickham Terrace, Brisbane, Queensand Genera Insurance Code of Practice Vero Insurance Limited (Vero) has adopted the Genera Insurance Code of Practice which has been deveoped by the Insurance Counci of Austraia. The Code is designed to promote good reations and good insurance practice between insurers, intermediaries and consumers. The Code sets out what insurers must do when deaing with poicyhoders/the insured. Pease contact Vero for more information about the Code, if required. Our Compaints Handing Procedures Resoving your compaints If you think we have et you down in any way, or our service is not what you expect (even if through one of our agents or representatives), pease te us so we can hep. You can te us by phone, in writing or in person. Shoud you te us in writing it wi hep to send us the fu detais of your compaint together with any supporting documents and an expanation of what you want us to do. If you woud ike to come in to tak to us face to face, pease ca and we wi arrange an appointment for a meeting. Page 2 of 8

3 What we wi do to resove your compaint When you first et us know about your compaint or concern the person trying to resove your compaint wi isten to you, consider the facts and contact you to resove your compaint as soon as possibe, usuay within 24 hours. If you are not satisfied with this person s decision on your compaint, then it wi be referred to the reevant Operationa Manager, who wi contact you within 5 working days. Shoud you not be satisfied with the Operationa Manager s decision, then it wi be referred to the Genera Manager (or their deegate). We wi send you our fina decision within 15 working days from the date you first made your compaint. What if you are not satisfied with our fina decision? We expect our procedures wi dea fairy and prompty with your compaint. However if you are not satisfied with our fina decision there are externa dispute remedies such as mediation, arbitration or ega action. Page 3 of 8

4 Guideines to hep you compete this Proposa Form 1. Faiure to discose a materia information that is ikey to infuence the acceptance of the risk or the terms appied coud invaidate the insurance. If you are in any doubt as to whether any information is materia, it shoud be discosed. 2. Where the space provided is insufficient for your repies, pease provide these separatey and attach to this Proposa Form. 3. Reference to Insured in this Proposa Form means: the entity or entities named in question 1; and the past and/or present empoyees, soe practitioners, partners or directors of the entity or entities named in question Reference to North America in this Proposa Form means the United States of America and Canada and their respective territories and protectorates. Section 1 detais of the insured 1. Name of a entities to be insured ABN: ABN: 2. Teephone Number ( ) Facsimie Number ( ) Emai Address Website Address 3. Address of Principa Office 4. Address(es) of other Office(s) State State State Postcode Postcode Postcode 5. Date business estabished 6. a) Pease ist a professiona services provided and aocate an approximate percentage of your fee income for each. Professiona Services b) Are there any intended changes to the professiona services described in Q6 a. Yes No If Yes, pease 7. Has the Insured been engaged in any other professiona service or activity other than described in 6a above? Yes No If Yes, pease Page 4 of 8

5 Section 1 detais of the insured (continued) 8. Name of a principas, directors, partners Age Quaifications Date Quaified How ong practising 9. Number of Principas and Staff Fu Time Part Time Directors, Partners, Principas Consutants Quaified/Technica Staff Administration/other Staff Tota a Staff 10. Has the Insured been invoved in any mergers or acquisitions in the ast five years? Yes No If Yes, pease 11. Has the Insured been invoved in any joint ventures in the ast five years? Yes No If Yes, pease 12. Is Previous Business cover required for the previous business of any principa, director or partner? Yes No If Yes, pease advise: Name of principa, director or partner Name of Previous Business Professiona Services Note: Previous Business cover is not automaticay incuded 13. Is the Insured required to be icenced or accredited in order to practice the professiona services for which cover is being requested? Yes No If Yes, has the icence or accreditation been in force at a reevant times? Yes No If No, pease 14. Is the Insured represented in any way outside Austraia? Yes No If Yes, pease state Country, Fees / Turnover, Number of Staff and Number of Offices Country Fees/Turnover Number of Staff Number of Offices $ $ $ 15. Is the Insured represented in any way in North America? Yes No If Yes, pease Page 5 of 8

6 Section 1 detais of the insured (continued) 16. Pease state gross fees / turnover (as appicabe), payabe by cients. Location Previous 12 months Last 12 months Next 12 months a) Austraia $ b) esewhere (excuding North America) $ c) in North America (incuding work performed outside those areas for persons, companies, firms, or organisations having an address therein) $ Tota of a), b) and c) above $ 17. Stamp Duty Decaration Pease provide a percentage breakdown of fees / turnover by ocation as foows NSW VIC QLD SA WA TAS ACT NT Overseas Tota Does the Insured subcontract any of their activities? Yes No If Yes, a) Pease state percentage of gross fees / turnover paid to subcontractors in the ast 12 months? b) What activities are subcontracted? c) Do a subcontractors have Professiona Indemnity Insurance? Yes No 19. Pease state the 3 argest contracts for the ast 5 years? Cient Name Project vaue Fees earned Year work performed 20. Does the Insured undertake any work which invoves the Insured in: a) manufacturing, construction, erection or instaation? Yes No If Yes, state what percentage of the tota fees / turnover decared in Q16 reates to such work b) the suppy of materias, pant, goods, or equipment? Yes No If Yes, state what percentage of the tota fees / turnover decared in Q16 reates to such work 21. Does the Insured have any Professiona Indemnity Insurance currenty in force? Yes No If Yes, pease state: Name of Insurer Limit of Indemnity Renewa Date Excess Retroactive Date Section 2 genera detais 1. Has any insurer, in respect of the risks to which this proposa reates, ever: a) decined a proposa, refused renewa or terminated an insurance? Yes No b) required an increased premium or imposed specia conditions? Yes No c) decined an insurance caim by the Insured or reduced its iabiity to pay an insurance caim in fu (other than by appication of an Excess)? Yes No If Yes to any of the above, pease give detais Page 6 of 8

7 Section 3 caims and circumstances 1. a) Has any caim been made against the Insured or any principa, partner or director (either as a principa, partner or director of the Insured or of any previous business), consutant or empoyee in respect of the risks to which Yes this proposa reates? b) Has the Insured or any principa, partner, director, consutant or empoyee incurred any other oss or expense which might be within the terms of the Professiona Indemnity cover? Yes No If Yes in either case, pease give detais Cost (if any) of Caim paid Date of Caim or oss Brief detais of each Caim or oss or oss insured Estimated outstanding oss No 2. What action has been taken to prevent a recurrence of the situation which gave rise to each caim or oss? 3. Is any principa, director, partner, consutant or empoyee, after enquiry, aware of any circumstances which might: a) give rise to a caim against the Insured or his/her predecessors in business or any of the present or former partners, principas, directors, consutants or empoyees? Yes No b) resut in the Insured or his/her predecessors in business or any of the present or former partners, directors, consutants, empoyees or principas incurring any osses or expenses which might be within the terms of the Professiona Indemnity cover? Yes No c) otherwise affect the Insurer s consideration of this Insurance? Yes No If Yes to any, pease give detais, incuding maximum potentia cost (by separate note if preferred) It is agreed that if such facts, circumstances or situations exist, whether or not discosed, any caim arising from them is excuded from this proposed insurance poicy. Section 4 Insurance 1. Pease state Limit of Indemnity required under this Professiona Indemnity insurance: $1,000,000 $2,000,000 $5,000,000 $10,000,000 $20,000,000 Other $ 2. Pease state Excess required (in most cases an Excess wi be compusory) $1,000 $2,500 $5,000 $7,500 $10,000 Other amount $ additiona information required Note: 1) A Suppementary Proposa Form is required for the foowing professions. It is avaiabe from Actuaries, Advertising Agents, Anthropoogists, Architects, Beauty Therapists, Buiding Inspectors, Computer Consutants, Conference and Exhibition Organisers, Consuting Chemists, Consuting Geoogists, Customs Agents, Educationa Estabishments, Empoyment Agents, Engineers, Environmenta Consutants, Funera Directors, Investigative Consutants, Loss Assessors, Medica Centres and Day Surgeries, Management and Human Resources Consutants, Mediators and Arbitrators, Nursing Homes and Aged Care, Patent Attorneys, Pubishers, Rea Estate Agents, Safety Consutants, Strata Pan Body Corporate Councis and Strata Managers, Surveyors, Transators, Trave Agents and Tour Operators, Vehice Inspectors, Veterinarians. 2) Specific Proposa Forms are required for Accountants, Finance Brokers and Mortgage Brokers. They are avaiabe from 3) Pease attach brochures, written agreements or conditions of contract in connection with the professiona services. Page 7 of 8

8 Decaration I/We the undersigned duy authorised person(s) decare that: i. I am/we are authorised by each of the Insured to sign this Proposa Form; and ii. the above statements are correct, true and compete; and iii. no information materia to this Proposa Form has been withhed; and iv. I/we have read the important facts which you have put before me/us and I/we understand the advice given in reation to the duty of discosure; and v. I/we have diigenty made a necessary and detaied enquiries in order to compy with the duty of discosure; and vi. I/we understand that no insurance is in force unti such time as the insurer has confirmed acceptance of the proposed insurance; and vii. I/we undertake to inform the insurer of any materia ateration to these facts occurring before competion of the contract of insurance; and viii. I/we acknowedge that the insurer reies on the information and representations in this Proposa Form and otherwise made by me/us in reation to this insurance; and ix. except where indicated to the contrary, I/we understand that any statement made in this Proposa Form wi be treated by the insurer as a statement made by a persons to be insured; and x. I/we have read Vero s Privacy Statement on this Proposa Form, and consent to the use, discosure and obtaining of persona information about the Insured for the purposes shown in the Privacy Statement. Signed Name of Partner(s) or Director(s) On Behaf of (Insert Name of Firm) Date How to contact Vero Profin New South Waes Queensand Victoria GPO Box 115, GPO Box 41 GPO Box 1509 Sydney NSW 2001 Brisbane QLD 4001 Mebourne VIC 3001 DX Sydney Stock Exchange DX 200 Brisbane DX 273 Mebourne Te (02) Te (07) Te (03) Fax (02) Fax (07) Fax (03) South Austraia Western Austraia GPO Box 1619 PO Box B78 Adeaide SA 5001 Perth WA 6838 DX 552 Adeaide DX 125 Perth Te (08) Te (08) Fax (08) Fax (08) Additiona information can be provided here. Page 8 of 8

9 professiona indemnity suppementary proposa for veterinarians Instructions for competing this Suppementary Proposa Form 1. Faiure to discose a materia information that is ikey to infuence the acceptance of the risk or the terms appied coud invaidate the insurance. If you are in any doubt as to whether any information is materia, it shoud be discosed. 2. Where the space provided is insufficient for your repies, pease provide these separatey and attach to this Suppementary Proposa Form. 3. Reference to Insured in this Suppementary Proposa Form means: the entity or entities named in question 1 the past and/or present empoyees or principas of the entity or entities; and the directors of the entity or entities and a subsidiary entities for whom cover is required. 1. Name of a entities to be insured 2. Date that the Proposa Form to which is this is a Suppementary Proposa Form was signed and dated 3. Does the Insured speciaise in any particuar branch of veterinary science? Yes No If Yes, pease 4. Pease detai the approximate percentage of the Insured s fee income derived from practice in reation to the foowing categories of anima: a) Domestic pets b) Farm animas c) Boodstock d) Stud stock e) Exotic animas f) Racehorses g) Greyhounds h) Artificia Breeding i) Equine (vaued under $20,000) j) Equine (vaued over $20,000) k) Animas vaued over $10,000 ) Other (pease specify) TOTAL 100 Insurer: Vero Profin, is a division of Vero Insurance Limited ABN V Page 1 of 2

10 Decaration I/We the undersigned duy authorised person(s) decare that: i. I am/we are authorised by each of the Insured to sign this Suppementary Proposa Form; and ii. the above statements are correct, true and compete; and iii. no information materia to this Suppementary Proposa Form has been withhed; and iv. I/we have read the important facts which you have put before me/us in the Professiona Indemnity Proposa Form and I/we understand the advice given in reation to the duty of discosure; and v. I/we have diigenty made a necessary and detaied enquiries in order to compy with the duty of discosure; and vi. I/we understand that no insurance is in force unti such time as the insurer has confirmed acceptance of the proposed insurance; and vii. I/we undertake to inform the insurer of any materia ateration to these facts occurring before competion of the contract of insurance; and viii. I/we acknowedge that the Insurer reies on the information and representations in this Suppementary Proposa Form and otherwise made by me/us in reation to this insurance; and ix. except where indicated to the contrary, I/we understand that any statement made in this Suppementary Proposa Form wi be treated by the insurer as a statement made by a persons to be insured; and x. I/we have read Vero s Privacy Statement which you have put before me/us in the Professiona Indemnity Proposa Form, and consent to the use, discosure and obtaining of persona information about the Insured for the purposes shown in the Privacy Statement; and xi. I/we acknowedge that this Suppementary Proposa forms part of the Professiona Indemnity Proposa Form signed and dated on the date discosed in question 2. Signed Name of Partner(s) or Director(s) On behaf of* Date Page 2 of 2

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