PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

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1 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 policy is issued on a `claims made basis. This means that the policy responds to: 1. Claims first made against the insured during the policy period and notified to the Insurer during that policy period, providing that the insured was not aware, at any time prior to the policy inception of any circumstances which would have alerted a reasonable person in the insured s position that a claim may be made against the insured: 2. Claims circumstances notified pursuant to Section 40(3) of the Insurance Contracts Act 1984 which states: Where the Insured gave notice in writing to the insurer of facts that might give rise to a claim against the insured as soon as was reasonable practicable after the insured became aware of those facts but before the insurance cover provided by the contract expired, the insurer is not relieved of liability under the contract in respect of the claim when made, by reason only that it was made after the expiration of the period of insurance cover provided by the contract. After policy expiry, no new claims can be made on the expired policy even though the event giving rise to the claim may have occurred during the policy period. If during the policy period you become aware of circumstances which a reasonable person in your position would consider may give rise to a claim, and which fail to notify us during the policy period, we may not cover you under a subsequent policy for any claim which arises from these circumstances. When completing the proposal form you are obliged to report and provide full details of all circumstances of which you are aware and which a reasonable person in your position would give rise to a claim. It is important that you make a proper disclosure (see Duty of Disclosure, below) so that your cover under any new policy with us is not compromised. Pursuant to the Insurance Contracts Act 1984 your duty to disclose all relevant information is set out below. Duty of Disclosure Before entering 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, and if so, on what terms. You have the same duty to disclose these matters to the insurer before you renew, extend, vary or reinstate a contract of insurance. Your duty however does not require the disclosure of matters: that diminishes the risk to be undertaken that is of common knowledge that your insurer knows, or in the ordinary course of their business, ought to know as to which compliance with your duty is waived by the insurer It should be noted your duty of disclosure continues after the proposal form has been completed until the policy is entered into. Non-Disclosure If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce 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. Retroactive Liability The proposed insurance may be limited by a retroactive date either stated in the schedule or endorsed onto the policy. Where the retroactive cover by the proposed policy is subject to such date, then the policy does not cover any claim arising from any actual or alleged act, error, omission or conduct occurring prior to such retroactive date. 1

2 Surrender or Waiver of any Right of Contribution or Indemnity If another person or company would be liable to compensate you or hold you harmless for part or all or any loss or damage otherwise covered by the policy, but you have agreed with that person or company, either before or after the inception of the policy, that you would not seek to recover any loss or damage from them, you are not covered under the policy for any such loss or damage. Privacy Lloyds and its agent are bound by the obligations of the Privacy Act 1988 as amended by the Privacy Amendment (Private Sector) Act 2000 regarding the collection, use, disclosure and handling of personal information. Only information necessary for the arrangement and administration of Lloyd s business by Lloyds, its agents and their representatives will be collected. This includes information necessary to accept the risk, to assess a claim, to determine competitive and appropriate premiums. Lloyds and its agents disclose personal information to third parties who they believe are necessary to assist them in doing. These parties will only use the personal information for the purposes we provided it to them for (or if required by law). When you give Lloyds and its agents personal information about other individuals, we rely on you to have made or make them aware that you will or may provide their personal information to us, the types of third parties we may provide it to, the relevant purposes we and the third parties we disclose it to will use if for, and how they can access it. You are entitled to access your information if you wish and request correction if required. Contact details for The Underwriters Agency are: Suite 1, Level2, Norton St, LEICHHARDT NSW 2040 Phone: (02) Fax: (02) Important information to complete the proposal form: Please answer all questions providing full and detailed information. Blanks, dashes or N/A are not acceptable. Please note that information contained in your website is not considered to satisfy your duty of disclosure and all material facts regarding the risk should be disclosed in the proposal form. If the space provided is insufficient to answer the question, please attach a signed and dated addendum. 2

3 1.YOUR DETAILS Name (include full legal name of each incorporated body, natural persons and trading names) Date of Commencement Are you registered for GST? ABN: Address Telephone No Other Location Website address 2. PRINCIPALS / EMPLOYEE INFORMATION a) Please provide details of the following: Principals/Partners/Directors Other Technical Staff Non-technical Staff Total Details of Principals /Partners/Directors Name Age Qualifications This Practice (yrs) Previous Practice (yrs) b) Are you a member in good standing of a professional association or society? Please provide full details including the name of the association and current status (where you are an incorporated body or Partnership, details must be given for each Principal) 3. PRACTICE DETAILS a) Has the name of the practice ever changed or traded under any other names? b) Have you purchased or merged with any other practice or business? c) Is any Partner/Principal/Director connected (financially or otherwise), with any other practice or business? d) Does this practice conduct work for or trade with any associated or related entities? If you have answered Yes to any of the above, please supply details below: 4. INSURANCE HISTORY a) Has the Practice or any Partner, Principal or Director: i) ever been refused this type of insurance? ii) had similar insurance cancelled? iii) had an application of renewal declined? iv) has special terms imposed? 3

4 b) Does the Practice currently carry, or has it ever carried, Professional Indemnity Insurance? INSURER PERIOD OF INSURANCE LIMIT OF INDEMNITY PREMIUM 5. PROFESSIONAL BUSINESS a) Please state fully the nature of your business, including clear details of the nature and type of advice given. (Please provide copies of any brochures or other documentation which may assist the Insurer in gaining a better appreciation of the risk being proposed). b) Please categorise the activities undertaken and indicate the percentage of your fee income each activity represents. c) Are verbal reports or advice always confirmed in writing? Please give details of what approximate percentage of reports have been given in the last 12 months as verbal reports only. d) Are written disclaimers included with advice being given? (If yes, please attach an example) e) Do you envisage any substantial changes in your activities or operations in the next 12 months? (If Yes, please provide details) f) Are you or have you or any parent, subsidiary or related entity either engaged in, or have/had a controlling share of an entity engaged in: i) Actual construction, fabrication, erection or any for of contracting? ii) Real Estate development? iii) The manufacture, sale or distribution of any product or process or patented production process? If Yes, please provide details including the names of the other entities involved, their relationship to you and full details of the nature of the involvement 6. SPECIFIC PROJECTS (construction prop only??) Have you ever undertaken work in respect of which with the potential professional liability arising therefrom has been or is protected by a specific project insurance policy? (If Yes, please provide details) 7. WORK (OUTSIDE AUSTRALIA/NEW ZEALAND) Do you or are you, likely to undertake, work outside of Australia or for clients located overseas? (If Yes, please provide details) 4

5 8. JOINT VENTURES Have you or any Principal been or currently are, a member of any Joint Venture (JV)? If Yes, please provide the description and nature of the JV project. Additional information may be requested depending on the nature, size and type of JV. 9. CONSULTANTS, SUB-CONSULTANTS AND AGENTS Do you engage consultants, sub-contractors or agents? If Yes, a) Do you insist they carry their own Professional Indemnity Insurance? b) Are there minimum sums insured that you require? c) Do you enter into any hold-harmless agreements or otherwise waive any legal rights or entitlements which you may have against consultants, sub-contractors or agents? If you have answered Yes to a, b or c above, please supply details. 10. SOLE TRADERS What arrangements do you have to cover the business or practice during your temporary absence while away on business, sick leave etc? 11. MISCELLANEOUS Does any one client (or group of companies) account for more than 50 of your income? If Yes, please state the approximate percentage of your income derived from the client or group of companies. Also, explain your relationship with the client and the nature of the work you perform for them. (Please attach separate sheet of paper if require). 12. RISK MANAGEMENT a) Do you have a documented Risk Management Program (consistent with Australian Standard AS/NZS 4360:1999) which addresses your professional duty risk? (If Yes, please provide a copy) b) What date was the program implemented? c) Is the program independently reviewed/monitored/audited? If Yes, please provide details d) When was the program last reviewed and updated to ensure it complies with the current Standards applying to your profession? e) Is there a principal/director/partner responsible for overseeing risk management within your Practice? 13. RETROACTIVE COVER Do you require retroactive cover which may be subject to additional premium? Retroactive cover extends cover under the Policy to liability arising from work carried to the inception of the Policy to which this Proposal relates. There will be no cover for Claims arising from Known Circumstances as at Policy Inception. Please state date from which retroactive cover is required: 5

6 14. FEE INCOME a) Please state your Gross Professional Fees over the periods stated. Include fees paid to sub-consultants appointed by you. Exclude fees collected for disbursement to Consultants appointed by your client together with travelling accommodation or similar expenses reimbursed by your clients. AUSTRALIA OVERSEAS Estimated Current Year Prior Financial Year Previous Financial Year b) Please provide a percentage breakdown of fee income disclosed in Q 14 (a) by State or Territory. ACT NSW VIC QLD SA WA TAS NT O SEAS TOTAL 15. CLAIMS AND CIRCUMSTANCES Please answer the following questions, after enquiry, within your organisation. a) During the past 10 years has any Claim been made, or has negligence been alleged, against you or any of the present or former Principals, or have any circumstances which may give rise to Claim against you or any of the present or former Principals been notified to insurers? If Yes, please give details for each matter. Date Insurer Claimant Matter Description Amount Paid/Outstanding b) Are there any Partners, Principals or Directors, after enquiry, aware of any Claim or has negligence been alleged, against your or any of the present or former Principals, or have any circumstances which may give rise to a Claim against you or any of the present or former Principals which has not been referred to in the previous question? If Yes, please give details for each matter. Claimant Matter Description Estimate c) Has any Principal or staff member ever been subject to disciplinary proceedings for Professional Misconduct? If Yes, please give details for each matter below. d) Are any of the Principals, Partners or Directors, after enquiry of all staff, managers and contractors, of any accounts overdue for payment where there is reason to believe that the client is dissatisfied with the professional services rendered? If Yes, please provide details below. 6

7 16. COVER REQUIRED Please state: a) Amount of preferred Total Sum Insured $ b) Amount of preferred excess (N.B. Your policy will be subject to a minimum excess) $ OPTIONAL EXTENSIONS 17. FIDELITY Do you require fidelity guarantee cover which may be subject to an additional premium? If Yes, please provide details: a) Sub-limit required: $50,000 $100,000 $250,000 N/A b) Have you ever sustained any loss through fraud or dishonesty of any employee? c) Are cash, securities and negotiable instruments subject to control by a partner, principal or director, or by at least two employees? d) Are cheques signed/co-signed by a partner, principal or director, or by at least two Employees? e) Are bank reconciliations carried out by someone not authorised to deposit into or withdraw from bank accounts? f) Do you always require and obtain satisfactory references before hiring employees If you have answered to any of the above questions, please supply the relevant details and indicate what extra precautions you take to minimise the chances of fraud and dishonesty of employees. 18. PRINCIPALS PREVIOUS BUSINESS COVER Do you require cover for any Principals in respect of their previous business? If Yes, please provide details: Name of Business Profession Trading Dates of Business Gross Professional Fees for From To last full year of trading If the previous business activities differ from the activities of the current business, please provide details. 19. ATTACHMENTS REQUIRED TO ASSIST IN THE ASSESSMENT OF YOUR PROPOSAL a) CV or resume for each Partner/Principal/Director/Senior Qualified Staff b) Copies of all brochures and promotional material c) Copies of all Disclaimers d) Copies of Risk Management Procedures e) Full Details of Claim Notifications f) Standard Contract Terms and Conditions identifying areas of Liability Limitations or Waiver of any rights 7

8 DECLARATION I/We hereby declared that: My/Our attentions has been drawn to the Important Notice at the beginning of this Proposal form and further I/We have read these notices carefully and acknowledge my/our understanding of their content by my/our signatures below. The above statements are truce, and I/We have not suppressed or mis-stated any facts and should any information give by me/us alter between the date of this Proposal form and the inception date of the insurance to which this Proposal relates I/We shall give immediately notice thereof. I/We authorise The Underwriters Agency Pty Ltd, to collect or disclose any personal information relating to this insurance to/from any insurers or insurance reference service. I/We have provided information above another individual I/We declare that the individual has been made aware of the fact. I/We also confirm that the undersigned is/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this Proposal form, and I/We complete this Proposal form on their behalf. To be signed by the Chairman/President/Managing Partner/Managing Director/Principal of the association/partnership/company/practice /Business. Name: Title: Date: Signature: Applicant 1 Applicant 2 It is important the signatory/signatories to the Declaration is/are fully aware of the scope of this insurance so that all questions can be answered. If in doubt, please contact your insurance broker since non-disclosure may affect an Insured s right of recovery under the policy or lead to the policy being voided. The Underwriters Agency Pty Ltd P O Box 802 Leichhardt NSW 2040 Ph (02) Fax (02) ABN AFSL

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