mayhave occurred during the period of insurance; Avoid the contract from its beginning, if your non-disclosure fraudulent

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "mayhave occurred during the period of insurance; Avoid the contract from its beginning, if your non-disclosure fraudulent"

Transcription

1 Arena Underwriting Pty Ltd ABN: AFSL: Suite 8, 12 Alma Road, New Lambn NSW 2305 Tel: Fax: PUBLIC & PRODUCTS VOLUNTARY LIABILITY WORKERS PROPOSAL PERSONAL FIRE ACCIDENT PROTECTION PROPOSAL following following complete complete Completed s should not be forwarded below privacy contact details. Completed s should be forwarded your insurance broker or Arena Underwriting Pty Ltd at address are liable pay an Excess under Policy, amount payable Arena This Underwriting Policy is subject Pty Ltd (ABN Insurance Contracts , AFSL Act ) Under (Arena) acts will as be agent calculated on behalf after deduction Calliden Insurance any input Limited tax credit (ABN 47 you , Act AFSL you ) have a duty (Calliden), disclosure. insurer product. are or may be entitled claim on payment Excess. If you are unsure about taxation implications Policy, you General Before Insurance you take out Code insurance Practice with us, you have a duty tell us should seek advice from your accountant or tax pressional. Calliden everything is a signary you know, General or could Insurance reasonably Code be expected Practice (Code). The Code aims raise standards service between insurers and ir cusmers. know, Calliden s is relevant service our standards decision are insure accordance you and with Code. Don t Prevent Our Right Recovery For any terms information insurance. about If you Code, are including not sure wher a copy something Code, is contact Us The or Liability Financial policy Ombudsman contains a provision Service which on 1300 states if you or visit surrender your right seek recovery from anor party for a loss covered by policy, we have a right reject any claim from you Duty You have Disclosure same duty inform us those matters you in relation loss. Wher renew, You extend, are entering vary, or reinstate in a Policy your for contract first insurance. time or are proposing renew, vary, extend or reinstate a Policy You have a duty disclosure: Your duty however does not require disclosure matters : Your Duty Reduce Disclosure risk for New Policies The Pressional Indemnity and Management Liability sections your policy are claims made sections. This means When answering Are common Our knowledge questions You must be honest and You have a duty under law tell Us anything known You, and which a reasonable We know person or, in circumstances, ordinary course would our business, include in ought answer Policy question. covers you We for will claims use made answers against in you deciding during wher period insure You know, and and anyone else be insured under Policy, and on what terms. Your Duty We have Disclosure indicated we for do Renewals not want know. If You have aly entered in a Policy and You are proposing renew, vary, This extend means or reinstate Policy Policy does not Your provide duty cover disclosure in relation changes. ; If you do not comply with your duty disclosure, we may be You entitled have a duty : tell Us everything You know, or could reasonably be expected Events which know, occurred is prior relevant period Our decision insurance insure or any You and terms insurance. If You are not sure wher something is relevant earlier You retroactive should inform date stipulated Us anyway. in Policy Schedule; Who Needs Cancel Tell contract Us? Claims made against you after expiry period It is important You understand You are answering Our questions in way Refuse pay claim insurance for Yourself even though and anyone event else giving You rise want claim be covered by Policy. mayhave occurred during period insurance; Avoid contract from its beginning, if your nondisclosure What You was Are fraudulent Not Required Disclose Claims possibility which was intimated in any way prior Your duty does not require disclosure matters : commencement period insurance; reduce Privacy Statement risk; The information collected on form will be used Claims rising from or attributable any facts, circumstances are common knowledge; assess your request for insurance and provide or insurance or occurrences noted on for current period We know or, in ordinary course Our business, ought know; and We share have your indicated information We do with not or want third know. parties, as defined in If You privacy Do Not policy, Tell in Us order undertake insurance services. If you do Claims rising from or attributable any facts, circumstances If You not do complete not answer Our questions form in in full, and way in accordance disclose everything with You know, or occurrences We may reduce which or you refuse were aware pay a and claim, knew or (or cancel ought Policy. your If duty You answer disclosure, Our questions Calliden may fraudulently, not be able We may provide refuse you pay a claim reasonably and treat have Policy realised) as never prior having commencement been in force. Privacy period insurance may give rise a claim. Statement Both Calliden and Arena respect Your privacy. Any personal information provided For by purposes You will be treated Policy, in a accordance claim means: with Privacy Act 1988 In (Cth). accordance This privacy with Calliden s notification privacy provides policy a you summary may obtain how Calliden and Arena treat Your personal information. access at any time information Calliden or its service a) written demand for compensation or damages or or Calliden and Arena primarily collect Your personal information via form assess Your request for insurance and administer Your providers hold on you. If you would like contact Calliden about Policy b) a civil seeking compensation or damages or or privacy, but may or would also use like obtain information a copy settle privacy an insurance policy you claim, provide or insurance services as requested by You, and also notify may You do about so through or one services or following promotions means: from time time. If You do obtain not provide privacy policy information online requested at You may breach your duty c) any disclosure, criminal charge Your application brought against may not You be alleging capable a Wrongful being accepted, by phone additional conditions 1111 may be imposed on any cover provided or Your Policy may not be able be administered. In order by provide its insurance services Calliden and Arena may need d) disclose a notice Your charge, personal formal information investigation third order parties or notice including, but not limited : agents, underwriters, advisors and brokers; claims management requiring and You or attend service an inquiry providers; or or claims s adjusters, ordered loss assessors NSW and 1565 or claims investigars; lawyers; reinsurers and reinsurance by brokers; an Inquiring and Body. Financial Ombudsman Service, or as required by law (for a full list see Calliden s and Arena s Privacy Policies). As explained above, policy, by its terms, does not provide In event a claim, Calliden and Arena may disclose Your personal information cover for (including claims made sensitive after information) expiry overseas period reinsurers insurance for purpose assessing Your claim. Calliden and Arena will only share information cover provided with third by parties Policy. where Calliden and Arena reasonably Tax (GST). If you are not registered for GST, in event a claim believe we will it is necessary reimburse you in assessing GST component Your insurance in addition claim and in providing Section products 40(3) and services Insurance requested. Contracts Act 1984 provides Calliden s amount and Arena s we pay. Privacy The amount Policies contain we are information liable pay about under how access an insurer and is correct not relieved personal from liability information under a about contract You and insurance also how complain Policy will about be reduced a breach by privacy. amount If You any would input tax like credit additional information respect about a claim privacy by reason or would only like obtain claim a copy was made Privacy Policies, you are or please may be contact entitled Calliden s claim Privacy for supply Officer by: goods or after expiry period insurance cover provided by Tel: services covered by payment. contract where insured has; Fax: If you +61 are 2 entitled an input tax credit for Premium you have Given notice in writing insurer, paid, you must inform us extent entitlement at or time you make a claim under Policy. We will not facts might give rise a claim against insured Mail: Privacy Officer, PO Box 348, Milsons Point. as soon as was reasonably practicable after insured You or can are download attributable a copy your failure Calliden s notify Privacy us Policy your entitlement by visiting (or became aware those facts, and expiry You correct can also entitlement) download a an copy input Arena s tax credit Privacy on Policy premium. by visiting If you Arena Voluntary Workers Personal Accident Proposal Form CLARE VW PA PROP

2 Arena Underwriting Pty Ltd ABN: AFSL: Suite 8, 12 Alma Road, New Lambn NSW 2305 Tel: Fax: PUBLIC & PRODUCTS VOLUNTARY LIABILITY WORKERS PROPOSAL PERSONAL FIRE ACCIDENT PROTECTION PROPOSAL following following complete complete Taxation Information are liable pay an Excess under Policy, amount payable If Insured Persons are not registered for GST, in event a claim We will reimburse Insured Persons GST component This Policy is subject Insurance Contracts Act Under will be calculated after deduction any input tax credit you in addition amount We pay. The amount Insured Person Act you have a duty disclosure. are or is liable may be entitled pay under claim Policy on payment will be reduced Excess. by If you amount any input tax credit Insured Person is or may be entitled are unsure claim about for supply taxation implications goods or services Policy, covered you by payment. Before you take out insurance with us, you have a duty tell us should seek advice from your accountant or tax pressional. If You are everything entitled an you input know, tax or credit could for reasonably Premium, be expected You must inform know, is relevant our decision insure you and Don t Us Prevent extent Our Right entitlement Recovery at or time Insured Person makes a claim under Policy. We will not indemnify Insured Persons or You for any GST liability, fines or penalties terms insurance. If you are not sure wher something is The Liability policy contains a provision which states if you arise from or are attributable Your failure notify Us Insured Person s or Your entitlement (or correct entitlement) an input surrender your right seek recovery from anor party for a loss tax credit on Premium. covered by policy, we have a right reject any claim from you If You Insured have Persons same duty are liable inform pay us an those Excess matters under Policy, you amount in relation payable will loss. be calculated after deduction any input tax credit renew, extend, vary, Insured or reinstate Person is your or may contract be entitled insurance. claim on payment Excess. If You Your or duty Insured however Persons does are not unsure require about disclosure taxation matters implications : Policy, You should seek advice from Your accountant or tax Reduce risk The Pressional Indemnity and Management Liability sections pressional. your policy are claims made sections. This means Don t Prevent Are common Our knowledge Right Recovery We know or, ordinary course our business, ought Policy covers you for claims made against you during period The Liability policy contains a provision which states if You surrender Your right seek recovery from anor party for a loss covered know, by and Policy, We have a right reject any Claim from You in relation loss. We have indicated we do not want know. This means Policy does not provide cover in relation ; If you do not comply with your duty disclosure, we may be entitled : Events which occurred prior period insurance or any earlier retroactive date stipulated in Policy Schedule; Cancel contract Claims made against you after expiry period Refuse pay claim insurance even though event giving rise claim mayhave occurred during period insurance; Avoid contract from its beginning, if your nondisclosure The information collected on form will be used assess your request for insurance and provide or insurance share your information with or third parties, as defined in privacy policy, in order undertake insurance services. If you do not complete form in full, and in accordance with your duty disclosure, Calliden may not be able provide you access at any time information Calliden or its service providers hold on you. If you would like contact Calliden about privacy, or would like obtain a copy privacy policy you may do so through one following means: obtain privacy policy online at by Tax (GST). If you are not registered for GST, in event a claim we will reimburse you GST component in addition amount we pay. The amount we are liable pay under Policy will be reduced by amount any input tax credit you are or may be entitled claim for supply goods or services covered by payment. If you are entitled an input tax credit for Premium you have paid, you must inform us extent entitlement at or time you make a claim under Policy. We will not or are attributable your failure notify us your entitlement (or correct entitlement) an input tax credit on premium. If you Claims possibility which was intimated in any way prior commencement period insurance; Claims rising from or attributable any facts, circumstances or occurrences noted on for current period Claims rising from or attributable any facts, circumstances or occurrences which you were aware and knew (or ought reasonably have realised) prior commencement period insurance may give rise a claim. For purposes Policy, a claim means: a) written demand for compensation or damages or or b) a civil seeking compensation or damages or or d) a notice charge, formal investigation order or notice requiring You attend an inquiry or or s ordered As explained above, policy, by its terms, does not provide cover for claims made after expiry period insurance cover provided by Policy. Section 40(3) Insurance Contracts Act 1984 provides in respect a claim by reason only claim was made after expiry period insurance cover provided by contract where insured has; Given notice in writing insurer, facts might give rise a claim against insured as soon as was reasonably practicable after insured became aware those facts, and expiry Arena Voluntary Workers Personal Accident Proposal Form CLARE VW PA PROP

3 PUBLIC & PRODUCTS VOLUNTARY LIABILITY WORKERS PROPOSAL PERSONAL FIRE ACCIDENT PROTECTION PROPOSAL DETAILS OF THE INSURED Name Insured following following complete complete are liable pay an Excess under Policy, amount payable This Policy is subject Insurance Contracts Act Under will be calculated after deduction any input tax credit you Postal Address Act you have a duty disclosure. are or may be entitled claim on payment Excess. If you are unsure about taxation implications Policy, you Suburb Before you take out insurance with us, you have a duty tell us should seek advice State from your accountant Postcode or tax pressional. everything you know, or could reasonably be expected Telephone know, Numbers is relevant Home our decision insure you and Don t Prevent Mobile Our Right Recovery terms insurance. If you are not sure wher something is The Liability policy contains a provision which states if you relevant Address you should inform us anyway. surrender your right seek recovery from anor party for a loss covered by policy, we have a right reject any claim from you You have same duty inform us those matters you in relation loss. renew, extend, vary, or reinstate your contract insurance. DETAILS OF THE EVENT Event Your Date duty however does not require disclosure matters : Reduce risk The Time Pressional Start Indemnity and Management Finish Liability sections your policy are claims made sections. This means Event Are Address common knowledge Location Name We know or, in ordinary course our business, ought Policy covers you for claims made against you during period Cover Commence Cover Expire know, and Number We have Guests indicated we do not want know. Indoors or This means Policy does not provide cover in relation ; If you do not comply with your duty disclosure, we may be Outdoors Nature entitled : event be Events which occurred prior period insurance or any earlier retroactive date stipulated in Policy Schedule; insured Cancel contract Claims made against you after expiry period Refuse pay claim insurance even though event giving rise claim GENERAL HISTORY mayhave occurred during period insurance; Has any Avoid insurer contract ever declined from its beginning, insure You if your or declined nondisclosure renew any Your Insurances or asked You agree Claims possibility which was intimated in any way prior special terms or conditions? If yes, please supply details Yes No commencement period insurance; The information collected on form will be used Claims rising from or attributable any facts, circumstances assess your request for insurance and provide or insurance or occurrences noted on for current period Are share You your aware information any circumstances with or third which parties, may as defined give rise in a Claim in given future? under any previous policy; If yes, privacy please policy, supply in order details undertake insurance services. If you do Claims rising from or attributable any Yes facts, circumstances No not complete form in full, and in accordance with or occurrences which you were aware and knew (or ought your duty disclosure, Calliden may not be able provide you reasonably have realised) prior commencement period insurance may give rise a claim. Do You carry out any activities outside Australia? For purposes Policy, a claim means: If yes, please supply details access at any time information Calliden or its service a) written demand for compensation or damages Yes or No or providers hold on you. If you would like contact Calliden about b) a civil seeking compensation or damages or or privacy, or would like obtain a copy privacy policy you may do so through one following means: obtain privacy policy online at CLAIMS HISTORY by d) a notice charge, formal investigation order or notice Have any claims been made against You in respect Your legal liability requiring for injury You or damage attend an in inquiry past or or 5 years? s ordered If yes, NSW please 1565 supply details Yes No Date Incident Nature Injury/Damage Amount Claim Tax (GST). If you are not registered for GST, in event a claim we will reimburse you GST component in addition amount we pay. The amount we are liable pay under Policy will be reduced by amount any input tax credit you are or may be entitled claim for supply goods or services covered by payment. If you are entitled an input tax credit for Premium you have paid, you must inform us extent entitlement at or time you make a claim under Policy. We will not or are attributable your failure notify us your entitlement (or correct entitlement) an input tax credit on premium. If you As explained above, policy, by its terms, does not provide cover for claims made after expiry period insurance cover provided by Policy. Section 40(3) Insurance Contracts Act 1984 provides in respect a claim by reason only claim was made after expiry period insurance cover provided by contract where insured has; Given notice in writing insurer, facts might give rise a claim against insured as soon as was reasonably practicable after insured became aware those facts, and expiry Arena Voluntary Workers Personal Accident Proposal Form CLARE VW PA PROP

4 PUBLIC & PRODUCTS LIABILITY PROPOSAL FIRE PROTECTION VOLUNTARY WORKERS DETAILS advise activities Your volunteer workers will be performing: 1. Performers please advise number volunteers undertaking type activity, and types performing activities: following complete are liable pay an Excess under Policy, amount payable This Policy is subject Insurance Contracts Act Under will be calculated after deduction any input tax credit you Act you have a duty disclosure. are or may be entitled claim on payment Excess. If you are unsure about taxation implications Policy, you Before you take out insurance with us, you have a duty tell us should seek advice from your accountant or tax pressional. everything you know, or could reasonably be expected 2. know, General is relevant Event Staff our decision please advise insure number you and volunteers undertaking type activity, and types general terms insurance. If you are not sure wher something is event activities being undertaken: You have same duty inform us those matters you renew, extend, vary, or reinstate your contract insurance. Your duty however does not require disclosure matters : Reduce risk Are common knowledge We know or, in ordinary course our business, ought know, and We have indicated we do not want know. The information collected on form will be used assess your request for insurance and provide or insurance Claims rising from or attributable any facts, circumstances or occurrences noted on for current period 4. Or Activities please advise full details any or activities insurance being undertaken or on any previous by volunteers or which not notice included had in been share your information with or third parties, as defined in privacy above: policy, in order undertake insurance services. If you do Claims rising from or attributable any facts, circumstances not complete form in full, and in accordance with or occurrences which you were aware and knew (or ought your duty disclosure, Calliden may not be able provide you reasonably have realised) prior commencement period insurance may give rise a claim. access at any time information Calliden or its service providers hold on you. If you would like contact Calliden about privacy, or would like obtain a copy privacy policy you may do so through one following means: obtain privacy policy online at by If Yes, please give relevant information: Tax (GST). If you are not registered for GST, in event a claim we will reimburse you GST component in addition amount we pay. The amount we are liable pay under Total number volunteers registered with Your event: Policy will be reduced by amount any input tax credit you are or may be entitled claim for supply goods or activity services under covered by Policy) payment. If you are entitled an input tax credit for Premium you have paid, you must inform us extent entitlement at or time you make a claim under Policy. We will not or are attributable your failure notify us your entitlement (or correct entitlement) an input tax credit on premium. If you CLARE VW PA APP 0913 Don t Prevent Our Right Recovery The Liability policy contains a provision which states if you surrender your right seek recovery from anor party for a loss covered by policy, we have a right reject any claim from you in relation loss. The Pressional Indemnity and Management Liability sections your policy are claims made sections. This means Policy covers you for claims made against you during period 3. Construction Related please advise number volunteers undertaking type activity, and types construction related activities being undertaken (jncluding This details means any rigging, Policy stage does construction, not provide cover seating in relation ; If you do not comply with your duty disclosure, we may be entitled construction, : infrastructure work etc): Events which occurred prior period insurance or any earlier retroactive date stipulated in Policy Schedule; Cancel contract Claims made against you after expiry period Refuse pay claim insurance even though event giving rise claim mayhave occurred during period insurance; Avoid contract from its beginning, if your nondisclosure Claims possibility which was intimated in any way prior commencement period insurance; For purposes Policy, a claim means: a) written demand for compensation or damages or or b) a civil seeking compensation or damages or or Has any person ever been injured whilst doing voluntary work for You? c) any criminal charge brought against Yes You alleging No a Wrongful Are re any exceptional circumstances relating risk be insured Act; or You have not Yes No aly ld Us about, and You know or should know may affect d) Our a notice decision charge, insure formal You? investigation order or notice requiring You attend an inquiry or or s ordered Will any volunteers be undertaking security related work at event (note is an excluded As explained above, policy, by its terms, does not provide cover for claims made after expiry period insurance cover provided by Policy. Section 40(3) Insurance Contracts Act 1984 provides in respect a claim by reason only claim was made after expiry period insurance Yes cover No provided by contract where insured has; Given notice in writing insurer, facts might give rise a claim against insured as soon as was reasonably practicable after insured became aware those facts, and expiry 3 Page Arena Voluntary Workers Personal Accident Proposal Form CLARE VW PA PROP

5 NCLAIMSHISTORY PUBLIC & PRODUCTS LIABILITY PROPOSAL FIRE PROTECTION DECLARATION I/We following complete (a) declare : (i) answers and information given by me/us in Proposal are true and correct in all respects; are liable pay an Excess under Policy, amount payable (ii) no information has been withheld which would affect This Policy is subject Insurance Contracts Act Under will be Calliden s calculated decision after deduction about accepting any input tax credit insurance; you Act (iii) you have where a duty answers disclosure. in Proposal are not my/own handwriting, are or may be y entitled have claim been on checked payment by me/us Excess. and I/we If you agree y are correct; are unsure about taxation implications Policy, you Before you take out insurance with us, you have a duty tell us (iv) I/we have and undersod clauses detailed should under seek advice from your accountant section or tax pressional. Proposal; everything you know, or could reasonably be expected know, is relevant our decision insure you and Don t Prevent Our Right Recovery terms (v) insurance. if re If you was are insufficient not sure wher space something fully answer is any The questions, Liability policy we have contains attached a provision supplementary which states pages if you relevant you should providing inform us anyway. additional information required; surrender your right seek recovery from anor party for a loss You have (vi) same I/we duty are inform authorised us those by matters Insured sign you Proposal covered Form; by policy, we have a right reject any claim from you in relation loss. renew, extend, vary, or reinstate your contract insurance. (b) authorise Calliden and Arena Underwriting Pty Ltd give Claims, or obtain Made from and Notified or insurers Policyor an insurance or Your duty however does not require disclosure matters : Reduce credit reference risk bureau, any information relating se The insurance Pressional covers, Indemnity and any and or Management insurances Liability held sections by me/us and claims under those insurances; your policy are claims made sections. This means Are common knowledge (c understand, if Proposal is accepted, my/our insurance We know or, in ordinary course our business, ought Policy covers will you be for subject claims made against terms you and during conditions period know, set and out in Arena Voluntary Workers Personal Accident Product Disclosure Statement and Insurance Policy; We (d have I acknowledge indicated we do not Calliden want and/or know. Arena Underwriting Pty Ltd, ir agents or employees reserve right decline Proposal. This means Policy does not provide cover in relation ; If you do not comply with your duty disclosure, we may be entitled : Events which occurred prior period insurance or any earlier retroactive date stipulated in Policy Schedule; Proposer s Signature.. Cancel contract Claims made against you after expiry period Refuse pay claim insurance even though event giving rise claim Proposer s Name & Title: mayhave occurred during period insurance; Avoid contract from its beginning, if your nondisclosure Claims possibility which was intimated in any way prior Date:./../.. commencement period insurance; The information collected on form will be used Claims rising from or attributable any facts, circumstances assess your request for insurance and provide or insurance or occurrences noted on for current period share your information with or third parties, as defined in DEQUATE privacy policy, S in order undertake insurance services. If you do Claims rising from or attributable any facts, circumstances not Completed complete s form should in full, be and forwarded in accordance your with insurance broker or occurrences or Arena which Underwriting you were aware Pty Ltd and at knew (or ought your duty disclosure, Calliden may not be able provide you address reasonably have realised) prior commencement period insurance may give rise a claim. access at any time information Calliden or its service providers hold on you. If you would like contact Calliden about privacy, or would like obtain a copy privacy policy you may do so through one following means: obtain privacy policy online at by Tax (GST). If you are not registered for GST, in event a claim we will reimburse you GST component in addition amount we pay. The amount we are liable pay under Policy will be reduced by amount any input tax credit you are or may be entitled claim for supply goods or services covered by payment. If you are entitled an input tax credit for Premium you have paid, you must inform us extent entitlement at or time you make a claim under Policy. We will not CLARE VW PA APP 0913 or are attributable your failure notify us your entitlement (or correct entitlement) an input tax credit on premium. If you For purposes Policy, a claim means: a) written demand for compensation or damages or or b) a civil seeking compensation or damages or or d) a notice charge, formal investigation order or notice requiring You attend an inquiry or or s ordered As explained above, policy, by its terms, does not provide cover for claims made after expiry period insurance cover provided by Policy. Section 40(3) Insurance Contracts Act 1984 provides in respect a claim by reason only claim was made after expiry period insurance cover provided by contract where insured has; Given notice in writing insurer, facts might give rise a claim against insured as soon as was reasonably practicable after insured became aware those facts, and expiry 4 P a g e Arena Voluntary Workers Personal Accident Proposal Form CLARE VW PA PROP

sp rts Sports Coaching & Clinics Insurance Application Form Underwriting Australia Sports Leisure Licensed Clubs

sp rts Sports Coaching & Clinics Insurance Application Form Underwriting Australia Sports Leisure Licensed Clubs sp rts Underwriting Australia Insurance Application Form Sports Leisure Licensed Clubs Please use this application for occupations relating to the including: Sports Clinics Sports Coaches School Sports

More information

ENTERTAINMENT & EVENTS LIABILITY INSURANCE

ENTERTAINMENT & EVENTS LIABILITY INSURANCE Arena Underwriting Pty Ltd ABN: 26 125 869 481 AFS: 317617 Suite 8, 12 Alma Road, New Lambton NSW 2305 Tel: 02 4952 4477 Fax: 02 4915 5376 www.arenaunderwriting.com.au ENTERTAINMENT & EVENTS LIABILITY

More information

DAWES MOTOR INSURANCE MOTORCYCLE CLAIM FORM IMPORTANT NOTICES

DAWES MOTOR INSURANCE MOTORCYCLE CLAIM FORM IMPORTANT NOTICES DAWES MOTOR INSURANCE MOTORCYCLE CLAIM FORM P.O. Box 2717 Taren Point NSW 2229 Phone: 1300 188 299 Fax: 1300 662 215 claims@dawes.com.au To ensure prompt attention to your claim, please complete this form

More information

Professional Indemnity Proposal

Professional Indemnity Proposal Professional Indemnity Proposal IMPORTANT NOTICES Your Duty Of Disclosure This Policy is subject to the Insurance Contracts Act 1984. Under that Act you have a duty of disclosure. Before you take out insurance

More information

Builders Warranty Claim Form

Builders Warranty Claim Form Builders Warranty Claim Form IMPORTANT NOTICES About the Insurer This insurance is underwritten by Great Lakes Reinsurance (UK) SE (ARBN 127 740 532, ABN 18 964 580 576, AFSL 318603) trading as Great Lakes

More information

Builders Warranty Claim Form

Builders Warranty Claim Form Builders Warranty Claim Form IMPORTANT NOTICES The Policy is issued by Calliden Agency Services Limited (CASL) (ABN 15 096 726 895, AFSL 234437) acting as agent for the insurer, Calliden Insurance Limited

More information

Public & Products Liability and Professional Indemnity Proposal Property Maintenance Contractors

Public & Products Liability and Professional Indemnity Proposal Property Maintenance Contractors Public & Products Liability and Professional Indemnity Proposal Property Maintenance Contractors IMPORTANT NOTICES Your Duty Of Disclosure This Policy is subject to the Insurance Contracts Act 1984. Under

More information

Business Insurance Proposal

Business Insurance Proposal Business Insurance Proposal Important Notices You must read the notices below. If you have any questions please contact GWS Genco Group (AFSL No. 231210) Duty of Disclosure This Policy is subject to the

More information

DAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM IMPORTANT NOTICES

DAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM IMPORTANT NOTICES DAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM PO Box 2717 Taren Point NSW 2229 Telephone: 1300 188 299 Facsimile: 1300 662 215 Email: claims@dawes.com.au www.dawes.com.au Before completing this claim

More information

Eligibility Application Form RBUA Builder Warranty Insurance (South Australia and Western Australia)

Eligibility Application Form RBUA Builder Warranty Insurance (South Australia and Western Australia) Eligibility Application Form RBUA Builder Warranty Insurance (South Australia and Western Australia) IMPORTANT NOTICES About Great Lakes Australia Great Lakes Reinsurance (UK) SE (ARBN 127 740 532, ABN

More information

Low Rise Multi Unit Development Project Application Form RBUA Builder Warranty Insurance (South Australia and Western Australia)

Low Rise Multi Unit Development Project Application Form RBUA Builder Warranty Insurance (South Australia and Western Australia) Low Rise Multi Unit Development Project Application Form RBUA Builder Warranty Insurance (South Australia and Western Australia) About the Insurer This insurance is underwritten by Great Lakes Reinsurance

More information

Public & Products Liability Proposal Form Standard

Public & Products Liability Proposal Form Standard Public & Products Liability Proposal Form Standard IMPORTANT NOTICES Your Duty Of Disclosure This Policy is subject to the Insurance Contracts Act 1984. Under that Act you have a duty of disclosure. Before

More information

Calliden Construction Work and Legal Liability

Calliden Construction Work and Legal Liability Calliden Construction Work and Legal Liability Insurance Proposal Important tices You must read the tices below. If you have any questions please contact your insurance adviser direct or our office. Visit

More information

1. NAME OF FIRM TO BE INSURED 2. ADDRESS OF FIRM 3. THE FIRM. (please include full names of all entities to be insured) Phone ( ) Email

1. NAME OF FIRM TO BE INSURED 2. ADDRESS OF FIRM 3. THE FIRM. (please include full names of all entities to be insured) Phone ( ) Email SURA Professional Risks Level 13 / 141 Walker St North Sydney NSW 2060 P O BOX 1813 North Sydney NSW 2059 Telephone. 02 9930 9500 Facsimile. 02 9930 9501 sura.com.au MISCELLANEOUS PROFESSIONAL INDEMNITY

More information

Professional indemnity insurance (including optional public and products liability insurance and employment practices liability insurance)

Professional indemnity insurance (including optional public and products liability insurance and employment practices liability insurance) Veterinarians Professional indemnity insurance (including optional public and products liability insurance and employment practices liability insurance) Proposal form 2011-2012 Please return completed

More information

Professional Indemnity Proposal Form

Professional Indemnity Proposal Form Professional Indemnity Proposal Form IMPORTANT NOTES This insurance cover is based upon representations given to us by you. Should any particulars have changed or be incorrect you must notify us immediately.

More information

Sports Injury Claim Form

Sports Injury Claim Form Sports Underwriting Australia Sports Underwriting Australia Claims Department PO E: liabilityclaims@sportsunderwriting.com.au Box 2717, Taren Point. NSW, 2229 Tel: Ph: 1300 363 363 413 413 Fax: +61 2 9524

More information

IMPORTANT NOTICE PLEASE READ THE FOLLOWING ADVICE BEFORE PROCEEDING TO COMPLETE THIS PROPOSAL FORM

IMPORTANT NOTICE PLEASE READ THE FOLLOWING ADVICE BEFORE PROCEEDING TO COMPLETE THIS PROPOSAL FORM IMPORTANT NOTICE PLEASE READ THE FOLLOWING ADVICE BEFORE PROCEEDING TO COMPLETE THIS PROPOSAL FORM Your Professional Indemnity Insurance Policy is issued on a CLAIMS MADE basis. This means that this policy

More information

4. DETAILS OF THE PRINCIPAL(S) OF THE FIRM How Long Practicing as Partner/Director

4. DETAILS OF THE PRINCIPAL(S) OF THE FIRM How Long Practicing as Partner/Director SURA Professional Risks Level 13 / 141 Walker St North Sydney NSW 2060 P O BOX 1813 North Sydney NSW 2059 Telephone. 02 9930 9500 Facsimile. 02 9930 9501 sura.com.au ACCOUNTANTS PROFESSIONAL INDEMNITY

More information

Real Estate Contractors ADDENDUM QUESTIONNAIRE. Please complete, sign and return with all attachments to: Name Position Address Email Phone

Real Estate Contractors ADDENDUM QUESTIONNAIRE. Please complete, sign and return with all attachments to: Name Position Address Email Phone Real Estate Contractors ADDENDUM QUESTIONNAIRE Please complete, sign and return with all attachments to: Name Position Address Email Phone If you have any questions regarding this form, please do not hesitate

More information

Claims Made Policy (applies to Professional Indemnity only) Your Duty of Disclosure. Excess. Your Legal Liability. Waiver of Rights.

Claims Made Policy (applies to Professional Indemnity only) Your Duty of Disclosure. Excess. Your Legal Liability. Waiver of Rights. Proposal Form Professional Indemnity & Public Liability Insurance for Swimming Pool Inspectors Arranged through ASR Underwriting Agencies Pty Ltd Underwritten by Certain Underwriters at Lloyd s IMPORTANT

More information

Professional Indemnity Proposal Form

Professional Indemnity Proposal Form Professional Indemnity Proposal Form BuildSafe Insurance Brokers Pty Ltd ABN 84 109 623 976 AFSL 279367 5 Peninsula Boulevard, Seaford, Vic. 3198 Postal: P. O. Box 2294 Seaford, Vic. 3198 Phone: 1300 763

More information

CONSTRUCTION INSURANCE OWNER BUILDER APPLICATION

CONSTRUCTION INSURANCE OWNER BUILDER APPLICATION SURA CONSTRUCTION PTY LTD LEVEL 13 / 141 WALKER ST NORTH SYDNEY NSW 2060 P O BOX 1813 NORTH SYDNEY NSW 2059 CONSTRUCTION INSURANCE OWNER BUILDER APPLICATION CONSTRUCTION INSURANCE OWNER BUILDER APPLICATION

More information

AAMT Massage Therapist Proposal Form Combined Malpractice, Public and Products Liability Insurance effective 30 September 2015

AAMT Massage Therapist Proposal Form Combined Malpractice, Public and Products Liability Insurance effective 30 September 2015 Page 1 of 5 AAMT Proposal Form Combined Malpractice, Public and Products Liability Insurance effective 30 September 2015 Please complete and return this proposal form via post, email or fax using the contact

More information

HOME INDEMNITY INSURANCE - WESTERN AUSTRALIA POLICY WORDING

HOME INDEMNITY INSURANCE - WESTERN AUSTRALIA POLICY WORDING POLICY WORDING HOME INDEMNITY INSURANCE - WESTERN AUSTRALIA GLA RBUA HII WA 1115 Effective Date 01 November 2015 Welcome to the financial security provided by RBUA Home Indemnity Insurance - Western Australia

More information

Find Me A Trainer Insurance Offer

Find Me A Trainer Insurance Offer Find Me A Trainer Insurance Offer Get Covered. Whether you are just starting out or have been in the industry for years, you will need Public Liability and Professional Indemnity insurance that protects

More information

Professional Indemnity Insurance Proposal.

Professional Indemnity Insurance Proposal. ProJuris Professional Indemnity Professional Indemnity Insurance Proposal. Important information What is a proposal? This proposal tells us information, which we need to know in order to decide whether

More information

Building Indemnity Insurance - South Australia Policy Wording

Building Indemnity Insurance - South Australia Policy Wording Building Indemnity Insurance - South Australia Policy Wording CBW BII SA 1213 Effective Date 01 December 2013 Welcome to the financial security provided by Calliden Building Indemnity Insurance - South

More information

LEADR Members. Professional indemnity insurance and public liability insurance. Proposal form 2014-2015

LEADR Members. Professional indemnity insurance and public liability insurance. Proposal form 2014-2015 LEADR Members Professional indemnity insurance and public liability insurance Proposal form 2014-2015 Please return completed proposal form to: Aon Risk Services Australia Limited ABN 17 000 434 720 Levels

More information

New Business Proposal

New Business Proposal MEDICAL MALPRACTICE COMBINED LIABILITY INSURANCE BIRTHING SUPPORT & EDUCATORS (Childbirth International) Important Notice: This is for a Medical Malpractice Combined Liability policy issued on a claims

More information

Members of the Institute of Arbitrators & Mediators of Australia (IAMA) Professional indemnity insurance and public liability insurance

Members of the Institute of Arbitrators & Mediators of Australia (IAMA) Professional indemnity insurance and public liability insurance Members of the Institute of Arbitrators & Mediators of Australia (IAMA) Professional indemnity insurance and public liability insurance Proposal form 2014-2015 Please return completed proposal form to:

More information

Professional indemnity insurance

Professional indemnity insurance Pest controllers Professional indemnity insurance Proposal form 2011-2012 Please return completed proposal form to your nearest Aon office (back page of proposal) Aon Risk Services Australia Limited ABN

More information

Professional Indemnity Proposal Form. for. Accountants. Address: 5/3352 Pacific Highway Postal: PO Box 976. Springwood QLD 4127 Springwood QLD 4127

Professional Indemnity Proposal Form. for. Accountants. Address: 5/3352 Pacific Highway Postal: PO Box 976. Springwood QLD 4127 Springwood QLD 4127 Professional Indemnity Proposal Form for Accountants Address: 5/3352 Pacific Highway Postal: PO Box 976 Springwood QLD 4127 Springwood QLD 4127 Phone: 07 3387 2800 Fax: 07 3208 2200 Email: pidirect@pidirect.com.au

More information

Home Warranty Insurance - Western Australia Insurance Policy

Home Warranty Insurance - Western Australia Insurance Policy Home Warranty Insurance - Western Australia Insurance Policy CBHWA WA 1208 Effective Date 01 December 2008 Important Information Duty of Disclosure This Policy is subject to the Insurance Contracts Act

More information

JUA Underwriting Agency Pty Ltd

JUA Underwriting Agency Pty Ltd JUA Underwriting Agency Pty Ltd Valuers Professional Indemnity Proposal Form Please answer every question fully, incomplete answers will not be accepted, and may result in a delay in terms being issued

More information

Proposal Form: Directors and Officers Insurance

Proposal Form: Directors and Officers Insurance Proposal Form: Directors and Officers Insurance Important Notice Relating to this Proposal PLEASE READ THE FOLLOWING ADVICE BEFORE PROCEEDING TO COMPLETE THIS PROPOSAL FORM. Your Directors & Officers Insurance

More information

4. DETAILS OF THE PRINCIPAL(S) OF THE FIRM How Long Practicing as Partner/Director

4. DETAILS OF THE PRINCIPAL(S) OF THE FIRM How Long Practicing as Partner/Director SURA Professional Risks Level 13 / 141 Walker St North Sydney NSW 2060 P O BOX 1813 North Sydney NSW 2059 Telephone. 02 9930 9500 Facsimile. 02 9930 9501 sura.com.au FINANCIAL PLANNERS PROFESSIONAL INDEMNITY

More information

Public and Products Liability Proposal Form

Public and Products Liability Proposal Form Public and Products Liability Proposal Form Solution Underwriting Agency Pty Ltd Level 5, 289 Flinders Lane Melbourne, Victoria. Australia 3000 T. 03 9654 6100 F. 03 9654 6200 www.solutionunderwriting.com.au

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT TICES - `CLAIMS MADE CONTRACTS OF INSURANCE Please read the following carefully before completing this proposal form: Your professional indemnity

More information

Professional indemnity insurance and optional public liability insurance

Professional indemnity insurance and optional public liability insurance Agricultural Consultants Professional indemnity insurance and optional public liability insurance Proposal form 2011-2012 Please return completed proposal form to: Aon Risk Services Australia Limited ABN

More information

Combined Professional Indemnity and Public Liability Insurance Proposal Form

Combined Professional Indemnity and Public Liability Insurance Proposal Form Combined Professional Indemnity and Public Liability Insurance Proposal Form Australian Institute of Landscape Designers and Managers Ltd and Australian Institute of Horticulture Inc Important Notice Relating

More information

Community Underwriting Personal Accident Claim Form

Community Underwriting Personal Accident Claim Form Community Underwriting Personal Accident Claim Form About the Insurer Calliden Insurance Limited (us/we/our) (Calliden) (ABN 47 004 125 268, AFSL 234438) is the insurer and issuer of this Policy and this

More information

Professional Trainers, Licensing Assessment and Consultancy Services Professional Indemnity and Public Liability Insurance Proposal Form

Professional Trainers, Licensing Assessment and Consultancy Services Professional Indemnity and Public Liability Insurance Proposal Form Tranznet Association Inc Arranges the insurance IMPORTANT INFORMATION Professional Trainers, Licensing Assessment and Consultancy Services Professional Indemnity and Public Liability Insurance Proposal

More information

JUA Underwriting Agency Pty Ltd

JUA Underwriting Agency Pty Ltd JUA Underwriting Agency Pty Ltd Engineers & Architects Professional Indemnity Proposal Form Please answer every question fully, incomplete answers will not be accepted, and may result in a delay in terms

More information

Breeze Underwriting Application Form Accountants Professional Indemnity Insurance

Breeze Underwriting Application Form Accountants Professional Indemnity Insurance Application Form Accountants Professional Indemnity Insurance Send quotation requests to: Email: distribution@breezeuw.com.au Phone: 1300 556 826 IMPORTANT NOTICES Please read these Important tices before

More information

Professional Trainers, Licensing Assessment and Consultancy Services Professional Indemnity and Public Liability Insurance Proposal Form

Professional Trainers, Licensing Assessment and Consultancy Services Professional Indemnity and Public Liability Insurance Proposal Form Tranznet Association Inc Arranges the insurance IMPORTANT INFORMATION Professional Trainers, Licensing Assessment and Consultancy Services Professional Indemnity and Public Liability Insurance Proposal

More information

AUCTIONEERS & VALUERS ASSOCIATION OF AUSTRALIA

AUCTIONEERS & VALUERS ASSOCIATION OF AUSTRALIA Professional Indemnity Insurance Proposal Form AUCTIONEERS & VALUERS ASSOCIATION OF AUSTRALIA IMPORTANT NOTICE Your Duty of Disclosure Before you enter into a contact of general insurance with any insurer,

More information

Entertainment & Event Liability Insurance Proposal

Entertainment & Event Liability Insurance Proposal Intermediary Date / / Contact Name Phone ( ) Period of Insurance to at 4.00pm INSURED DETAILS Insured Name / ABN (Full details required, inc. Trading Name if Applicable) ABN: Address / Situation Description

More information

MOTOR VEHICLE PROPOSAL FORM

MOTOR VEHICLE PROPOSAL FORM Commercial and Trucksure Pty Ltd As agent for the Insurer ABN: 78 078 661 220 AFSL: 238151 Level 6, 3 Spring Street Sydney NSW 2000 PO Box R1940 Royal Exchange NSW 1225 Telephone: (02) 9251 1155 Facsimile:

More information

Will you be claiming any Input Tax Credits on the GST applicable to this policy? Yes No If Yes, what percentage? % Suburb State Postcode

Will you be claiming any Input Tax Credits on the GST applicable to this policy? Yes No If Yes, what percentage? % Suburb State Postcode Accountants Professional Indemnity Insurance. Proposal Form Please complete and return this proposal form to Aon Risk Services Australia Ltd, GPO Box 1230, Melbourne VIC 3001 If you have any questions,

More information

Coversure Security Industry Insurance Proposal

Coversure Security Industry Insurance Proposal Intermediary Date / / Contact Name Phone ( ) Period of Insurance to at 4.00pm INSURED DETAILS Insured Name / ABN (Full details required, inc. Trading Name if Applicable) Postal Address Location of Premises

More information

Calliden Builder Warranty Insurance. South Australia and Western Australia. About Calliden. The Agent. Privacy Statement. Important Information

Calliden Builder Warranty Insurance. South Australia and Western Australia. About Calliden. The Agent. Privacy Statement. Important Information Low Rise Multi Unit Development Project Application Form Calliden Builder Warranty Insurance (South Australia and Western Australia) About Calliden Calliden Insurance Limited (Calliden) (ABN 47 004 125

More information

ACE Insurance Limited ELITE II PROFESSIONAL INDEMNITY INSURANCE POLICY

ACE Insurance Limited ELITE II PROFESSIONAL INDEMNITY INSURANCE POLICY ELITE II PROFESSIONAL INDEMNITY INSURANCE POLICY Renewal Proposal Form - Miscellaneous ABN 23 001 642 020 AFSL 239687 Page 1 of 8 ACE ELITE II PROFESSIONAL INDEMNITY INSURANCE RENEWAL PROPOSAL FORM Miscellaneous

More information

Professional Indemnity Proposal Form. for. Information Technology Consultants

Professional Indemnity Proposal Form. for. Information Technology Consultants Professional Indemnity Proposal Form for Information Technology Consultants Address: 5/3352 Pacific Highway Postal: PO Box 976 Springwood QLD 4127 Springwood QLD 4127 Phone: 07 3387 2800 Fax: 07 3208 2200

More information

DIRECTORS & OFFICERS LIABILITY INSURANCE PROPOSAL FORM IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS PROPOSAL

DIRECTORS & OFFICERS LIABILITY INSURANCE PROPOSAL FORM IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS PROPOSAL DIRECTORS & OFFICERS LIABILITY INSURANCE PROPOSAL FORM IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS PROPOSAL A. Obtaining a Quotation To minimise delays in obtaining

More information

Home Indemnity Insurance - Western Australia Policy Wording

Home Indemnity Insurance - Western Australia Policy Wording Home Indemnity Insurance - Western Australia Policy Wording CBW HII WA 1213 Effective Date 01 December 2013 Welcome to the financial security provided by Calliden Home Indemnity Insurance - Western Australia

More information

Professional Indemnity Insurance Application Form for Eligible Midwives

Professional Indemnity Insurance Application Form for Eligible Midwives Professional Indemnity Insurance Application Form for Eligible Midwives This Form will be used by MIGA to consider your application for Professional Indemnity Insurance with MIGA and for your automatic

More information

LABOUR FORCE PROFESSIONAL LIABILITY INSURANCE PROPOSAL FORM

LABOUR FORCE PROFESSIONAL LIABILITY INSURANCE PROPOSAL FORM SURA LABOUR HIRE PTY LTD SUITE 1.04 29 31 LEXINGTON DRIVE BELLA VISTA NSW 2153 TELEPHONE. 02 9672 6088 SURA.COM.AU LABOUR FORCE PROFESSIONAL LIABILITY INSURANCE PROPOSAL FORM IMPORTANT NOTICES The information

More information

NEW ZEALAND PSYCHOLOGICAL SOCIETY MEMBERS INSURANCE COVER As the insurance brokers to the NZ Psychological Society, Rothbury-Wilkinson Insurance

NEW ZEALAND PSYCHOLOGICAL SOCIETY MEMBERS INSURANCE COVER As the insurance brokers to the NZ Psychological Society, Rothbury-Wilkinson Insurance NEW ZEALAND PSYCHOLOGICAL SOCIETY MEMBERS INSURANCE COVER As the insurance brokers to the NZ Psychological Society, Rothbury-Wilkinson Insurance Brokers Ltd have arranged an insurance policy designed to

More information

Professional indemnity insurance

Professional indemnity insurance Professional indemnity insurance 2014 mini policy for CPA Australia members What is CPA Australia s mini policy? Fenton Green & Co. has arranged a professional indemnity insurance (Pll) mini policy (mini

More information

Professional Indemnity Proposal Form Agricultural Consultants

Professional Indemnity Proposal Form Agricultural Consultants Rivers Insurance Brokers Pty Ltd (t) 07 3028 9494 PO Box 518, Annerley Qld 4103 (f) 07 3891 3111 23 Balaclava Street, Woolloongabba Qld 4102 ABN 28 010 242 681 AFS Lic. 247093 admin@riversinsurance.com.au

More information

Proposal Form: Group Personal Accident Insurance

Proposal Form: Group Personal Accident Insurance Important tice Relating to this Proposal PLEASE READ THE FOLLOWING ADVICE BEFORE PROCEEDING TO COMPLETE THIS PROPOSAL FORM. Your Duty of Disclosure Before you enter into a contract of general insurance

More information

Community Underwriting Motor Claim Form

Community Underwriting Motor Claim Form Community Underwriting Motor Claim Form About the Insurer Calliden Insurance Limited (Calliden) (ABN 47 004 125 268), is a public company incorporated in Australia. It is authorised under the Australian

More information

Mortgage & Finance Brokers Professional Indemnity Insurance

Mortgage & Finance Brokers Professional Indemnity Insurance Mortgage & Finance Brokers Professional Indemnity Insurance Insurance House is extremely proud of our long standing association with the finance industry which has allowed us to construct a policy which

More information

Professional Indemnity Insurance Application Form Marsh Accountants Insurance Program

Professional Indemnity Insurance Application Form Marsh Accountants Insurance Program Professional Indemnity Insurance Application Form Marsh Accountants Insurance Program Phone: 1300 093 634 Email: accountants@marsh.com tice to the Applicant This notice must be read before you complete

More information

Application Form and Insurance Information

Application Form and Insurance Information Application Form and Insurance Information Family Day Care Australia Educator Insurance 9 Insurance Application Form C A O OFFICE USE ONLY Applicant Details Name of family day care coordination unit you

More information

Proposal Form. Management Consultants Professional Liability Insurance

Proposal Form. Management Consultants Professional Liability Insurance Management Consultants Professional Liability Insurance BusinessGuard AIG Australia Limited (AIG), ABN 93 004 727 753 AFSL 381686, Level 12, 717 Bourke Street, Docklands VIC 3008 Important Notice Claims-Made

More information

Proposal Form Australian Institute of Horticulture Professional Indemnity Insurance

Proposal Form Australian Institute of Horticulture Professional Indemnity Insurance Proposal Form Australian Institute of Horticulture Professional Indemnity Insurance Important Notice Relating to this Proposal PLEASE READ THE FOLLOWING ADVICE BEFORE PROCEEDING TO COMPLETE THIS PROPOSAL

More information

Engineers, Architects, Surveyors and Relation Professions

Engineers, Architects, Surveyors and Relation Professions Application Form Professional Indemnity Insurance Send quotation requests to: Email: distribution@breezeuw.com.au Phone: 1300 556 826 Engineers, Architects, Surveyors and Relation Professions IMPORTANT

More information

Public & Products Liability Proposal Form Go Kart Centres

Public & Products Liability Proposal Form Go Kart Centres Public & Products Liability Proposal Form Go Kart Centres IMPORTANT NOTICES Your Duty Of Disclosure This Policy is subject to the Insurance Contracts Act 1984. Under that Act you have a duty of disclosure.

More information

Public Relations / Marketing Consultants. Professional Indemnity Insurance

Public Relations / Marketing Consultants. Professional Indemnity Insurance Public Relations / Marketing Consultants Public Relations Consultants Marketing Consultants Market Research Consultants Advertising Consultants Graphic Designers Professional Indemnity Insurance Proposal

More information

Professional Indemnity Insurance AILA Proposal

Professional Indemnity Insurance AILA Proposal Professional Indemnity Insurance AILA Proposal September 2013 Please return this completed proposal to: Lynn Wainstein Lauren Malkin Tel (03) 9613 1442 Tel (03) 9613 1423 Email Lynn.Wainstein@jlta.com.au

More information

Professional Indemnity Insurance and optional Public & Products Liability

Professional Indemnity Insurance and optional Public & Products Liability Advantedge Members (Incorporating PLAN, FAST and CHOICE Members) Professional Indemnity Insurance and optional Public & Products Liability Proposal form 2014-2015 Please return completed proposal form

More information

Professional Indemnity Insurance

Professional Indemnity Insurance QBE Insurance (Australia) Limited ABN 78 003 191 035 Professional Indemnity Insurance Application Form Pool Safety Inspectors Notice to the Applicant This notice must be read before you complete the Application

More information

SHORT FILMS, TV COMMERCIALS, DOCUMENTARIES AND MUSIC VIDEOS PROPOSAL FORM

SHORT FILMS, TV COMMERCIALS, DOCUMENTARIES AND MUSIC VIDEOS PROPOSAL FORM SURA FILM AND ENTERTAINMENT PTY LTD LEVEL 13 / 141 WALKER ST NORTH SYDNEY NSW 2060 PO BOX 1813 NORTH SYDNEY NSW 2059 SHORT FILMS, TV COMMERCIALS, DOCUMENTARIES AND MUSIC VIDEOS PROPOSAL FORM 09-15 SHORT

More information

Australian Institute of Professional Photography photographic insurance application form

Australian Institute of Professional Photography photographic insurance application form Australian Institute of Professional Photography Please Return the Completed Application to: Marsh Pty Ltd Consumer Professional Photographers Insurance GPO Box 1229, Melbourne Vic 3001 Telephone: 1300

More information

Professional Indemnity Insurance for the Planning Profession

Professional Indemnity Insurance for the Planning Profession Professional Indemnity Insurance for the Planning Profession Important Notices Claims Made Policy This Proposal is for a policy issued by the insurer on a claims made and notified basis. This means that

More information

Institute of Mercantile Agents Combined Professional Indemnity and Public Liability Insurance Proposal Form

Institute of Mercantile Agents Combined Professional Indemnity and Public Liability Insurance Proposal Form Institute of Mercantile Agents Combined Professional Indemnity and Public Liability Insurance Proposal Form Important Notice Relating to this Proposal PLEASE READ THE FOLLOWING ADVICE BEFORE PROCEEDING

More information

Landlords Insurance. Application

Landlords Insurance. Application Landlords Insurance Application Landlords Insurance Application Form Important Information Product Disclosure Statement This application is for Australian Unity Landlords Insurance. Please read the product

More information

PROFESSIONAL INDEMNITY RENEWAL DECLARATION IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS RENEWAL DECLARATION

PROFESSIONAL INDEMNITY RENEWAL DECLARATION IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS RENEWAL DECLARATION PROFESSIONAL INDEMNITY RENEWAL DECLARATION IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS RENEWAL DECLARATION A. Obtaining a Quotation To minimise delays in obtaining

More information

Miramar Broadform Liability Insurance Proposal

Miramar Broadform Liability Insurance Proposal Miramar Broadform Liability Insurance Proposal IMPORTANT NOTES YOUR DUTY OF DISCLOSURE Before You enter into a contract of general insurance with an insurer, You have a duty, under the Insurance Contracts

More information

Professional Indemnity MISCELLANEOUS PROPOSAL

Professional Indemnity MISCELLANEOUS PROPOSAL Professional Indemnity MISCELLANEOUS PROPOSAL Please complete, sign and return with all attachments to: Name Position Address Email Phone If you have any questions regarding this form, please do not hesitate

More information

General Liability Insurance GROUP PTY LTD. Proposal Form. RSM GROUP Pty Ltd - Wholesale Broking

General Liability Insurance GROUP PTY LTD. Proposal Form. RSM GROUP Pty Ltd - Wholesale Broking GROUP PTY LTD General Liability Insurance Proposal Form RSM GROUP Pty Ltd - Wholesale Broking ABN 40 006 361 226 AFS Licence No. 239631 380-382 Canterbury Road, Surrey Hills Vic 3127 Private Bag 4000 Surrey

More information

Professional Indemnity Proposal Form. for. Financial Planners

Professional Indemnity Proposal Form. for. Financial Planners Professional Indemnity Proposal Form for Financial Planners Address: 5/3352 Pacific Highway Postal: PO Box 976 Springwood QLD 4127 Springwood QLD 4127 Phone: 07 3387 2800 Fax: 07 3208 2200 Email: pidirect@pidirect.com.au

More information

Professional Indemnity Proposal Form. for. Finance & Mortgage Brokers

Professional Indemnity Proposal Form. for. Finance & Mortgage Brokers Professional Indemnity Proposal Form for Finance & Mortgage Brokers Address: 5/3352 Pacific Highway Postal: PO Box 976 Springwood QLD 4127 Springwood QLD 4127 Phone: 07 3387 2800 Fax: 07 3208 2200 Email:

More information

Professional Indemnity Insurance Proposal Form for the Horticulture Industry

Professional Indemnity Insurance Proposal Form for the Horticulture Industry Professional Indemnity Insurance Proposal Form for the Horticulture Industry Important Notices Claims Made Insurance This is a proposal for a Claims Made policy of insurance. This means that the policy

More information

Public & Products Liability Claim Form

Public & Products Liability Claim Form Public & Products Liability Claim Form IMPORTANT NOTICES Purpose of this Claim Form The completion of this form is to report any incident: Which has the potential to result in an injury, damage and/or

More information

Contractual Liability

Contractual Liability Contractual Liability Claim Form IMPORTANT NOTES FOR YOUR INFORMATION 1 Ensure you: a. observe the principles of Utmost Good Faith, b. comply with your Duty of Disclosure, c. comply with the General Condition

More information

IMPORTANT NOTICES: Your duty, however, does not require disclosure of matter:

IMPORTANT NOTICES: Your duty, however, does not require disclosure of matter: IMPORTANT NOTICES: CLAIMS MADE POLICY This Proposal is for a policy issued by ProRisk on a claims made and notified basis. This means that the policy only covers claims first made against you during the

More information

Proposal Form: Management Liability Insurance

Proposal Form: Management Liability Insurance Important Notice Relating to this Proposal PLEASE READ THE FOLLOWING ADVICE BEFORE PROCEEDING TO COMPLETE THIS PROPOSAL FORM. Your Management Liability Insurance Policy is issued on a CLAIMS MADE basis.

More information

Proposal Form Information Technology Liability Insurance

Proposal Form Information Technology Liability Insurance Proposal Form Information Technology Liability Insurance Important Notice Relating to this Proposal PLEASE READ THE FOLLOWING ADVICE BEFORE PROCEEDING TO COMPLETE THIS PROPOSAL FORM. Your Information Technology

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT FACTS RELATING TO THIS PROPOSAL FORM The Purpose of this Proposal Form is to set out all relevant information for your adviser to submit on your

More information

Dental Practitioner Proposal for Dental Indemnity Policy Support Protect Promote

Dental Practitioner Proposal for Dental Indemnity Policy Support Protect Promote Support Protect Promote Dental Practitioner Proposal for Dental Indemnity Policy Support Protect Promote This is a proposal for a Dental Indemnity Policy underwritten by MDA National Insurance Pty Ltd

More information

Proposal Form. Architects Professional Indemnity

Proposal Form. Architects Professional Indemnity Proposal Form Architects Professional Indemnity Important Notices Please read these notices before completing the Proposal Form. Your Duty of Disclosure Before you enter into a contract of general insurance

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM Answer all questions. Blanks &/or dashes, or answers known to underwriters or brokers or N/A are not acceptable & will delay consideration of this proposal.

More information

CGU Padlock. insurance application

CGU Padlock. insurance application CGU Padlock insurance application CGU Insurance Limited ABN 27 004 478 371 Please read the following information before you complete the application. Keep this information for your records. Please read

More information

MEDIATORS DECLARATION PEACEWISE MASTER POLICY

MEDIATORS DECLARATION PEACEWISE MASTER POLICY Marsh Pty Ltd ABN 86004651512 PO Box H176 AUSTRALIA SQUARE NSW 1215 PROFESSIONAL INDEMNITY INSURANCE MEDIATORS DECLARATION PEACEWISE MASTER POLICY Professional Indemnity Declaration for Mediators who have

More information

SOLICITORS EXCESS PROFESSIONAL INDEMNITY PROPOSAL FORM IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS PROPOSAL

SOLICITORS EXCESS PROFESSIONAL INDEMNITY PROPOSAL FORM IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS PROPOSAL SOLICITORS EXCESS PROFESSIONAL INDEMNITY PROPOSAL FORM IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS PROPOSAL A. Your Duty of Disclosure Before you enter into a contract

More information

actual or alleged facts that might give rise to a Claim which were known to the Insured prior to the commencement of the Policy Period;

actual or alleged facts that might give rise to a Claim which were known to the Insured prior to the commencement of the Policy Period; Important Notice Signed is Required It is a condition of this policy that the Insured shall provide to AIG Australia Limited a signed and dated hard copy of this proposal form within 14 days of the policy

More information

Professional Indemnity Proposal form

Professional Indemnity Proposal form Important Information Please read this first Professional Indemnity Proposal form Important facts relating to this proposal form You should read the following advice before proceeding to complete this

More information