Church Insurance. Proposal Form

Transcription

1 Church Insurance Proposal Form

2 Church Insurance Proposal Form To complete this form: Print form Use black pen to fill in details Attach additional page(s) if insufficient space Please send completed Church Insurance Proposal (including any attachments) to ACS Insurance Services: E [email protected] T F PO Box 346, Camberwell VIC 3124 Section A. General Information Church/Ministry Name Contact Person Position Postal Address Phone (BH) Please include Area Code Suburb State Postcode Mobile Fax Please include Area Code Website ABN CODE: (Office use only) 1. Is the church affiliated with any group or denomination? AOG/ACC CRC/BETHESDA Crosslink CCC CLCI Other - please specify: 2. Is the organisation a church or separate ministry? If separate ministry, please describe its activities: Church Separate Ministry 3. Do your activities extend, or have they ever extended, outside the Commonwealth of Australia? 4. Are you currently insured? If yes, which type of policies? ISR Public Liability Professional Indemnity Associations Liability Voluntary Workers Personal Accident Directors & Officers Current Insurer: If no, please provide previous Insurance history: 2 of 9

3 Section A. General Information (cont.) 5. Total number of: a) Churches Average number attending b) Pastors Salaried Counsellors Full time Part time c) Retirement Homes Number of residents in: Units Hostels Nursing Homes d) Rehabilitation Centres Number of residents e) Child Care Centres (i) On average, how many children attend a centre per day? (ii) How many days per week are centres open? (iii) Are there professional/qualified carers in attendance? (iv) What is the child/carer ratio? (v) Are the parents with their children during care? f) Schools Primary Teachers Students Secondary Teachers Students g) Op Shops Details h) Care Arms Details i) Counselling Ministries Details j) Other (please give details) Section B. Property 1. Street Address of the locations: Location one Postcode Own Lease Location two Postcode Own Lease 2. Level of cover required: (All Buildings and Contents should be insured for replacement value) If your property has more than two buildings, please list separately the value of each building and the total value of the contents it contains. If more room is required, please continue on a separate sheet and attach to the proposal form. Replacement value of: Location one Location two Building Contents External Works Removal of Debris Professional Fees te: Please provide a copy of the most recent valuation. If leasing your premises, do you require glass cover? a) Do you use the building for purposes other than a church? b) In what year was the building constructed? 3 of 9

4 Section B. Property (cont.) Location one Location two c) If the building is over 30 years old, has it been rewired? If yes, what date was it rewired? d) Construction materials of exterior walls Concrete Brick Concrete Brick e) Construction materials of roof Iron Tiles Iron Tiles f) Construction materials of floors Concrete Concrete g) Are you aware of any asbestos material forming part of the building? If yes, provide copy of your asbestos register & remedial plans h) Describe the condition of the building i) Number of storeys, including Ground Good Fair Poor Good Fair Poor j) Is the building connected to Town water? If no, please advise details of water supply: k) How are the premises protected against fire? (i) Fire sprinkler system (ii) Smoke or heat detection equipment connected to fire brigade (iii) Hose reels to cover whole floor area (iv) Portable fire extinguisher Do you have regular maintenance checks of fire protection equipment? l) Do you have a commercial kitchen in your premises? Do you have a deep fryer? Does the kitchen contain cooking hoods, filters and ducted exhaust? Are the hoods, filters and ducting cleaned by a service contractor? If yes, what is the cleaning interval? 3. Does the property have security measures? Deadlocks Local Alarm Monitored Alarm* CCTV Window Locks Security Patrols *Monitored Alarm: An alarm that is monitored by an external security company who can contact the premises/administrator or send a security vehicle in response to an alarm event and provide an activity statement of that alarm event. 4. Do you require cover for the following? Machinery Breakdown (for motors over 2HP) Electronic Breakdown (for computers) These covers need to be individually assessed by our office. If you tick yes, one of our Insurance consultants will contact you for further details. 4 of 9

5 Section C. Public Liability 1. Do you have a Risk Management Committee in place? 2. Do you have any outreach/satellite churches that require cover under your insurance? Outreach Name Average number of people attending 3. Do you hold/are you involved in any event to which over 500 people attend? For example, Christmas Carols, Conferences etc. If yes, are any of the following involved? a) Fireworks/pyrotechnics b) Jumping castle/children s rides c) Live animals d) Outside contractors (eg. sound/lighting/stage etc.) 4. Is your Youth Group involved in any of the following activites? Please tick all that apply: Rock climbing Gladiator games White water rafting Water skiing Teams in sporting competitions Hang gliding/para gliding High/low rope courses Skateboarding/Rollerblading Surfing Car rally/go carts Flying fox Sumo wrestling Please te: Extra premiums and special conditions apply to some of these activities. 5. Do you have a Child Protection Policy in place? 6. Have all teachers/adult carers/leaders been Police checked and cleared in all states of Australia? 7. Have you ever received a complaint from a child, their parents or any other party about issues relevant to molestation/inappropriate behaviour in regard to any teachers, adult carers, leaders, counsellors etc. currently or previously working under your direction? 8. Are there any known molestation offenders who work under your direction? 5 of 9

6 Section D. Product Sales/Distribution 1. Do you produce any of the following for sale or distribution? a) Publications b) Music (CDs etc) c) Radio/TV Programs If yes to any of the above, please provide details: Section E. Motor Vehicle Insurance 1. Do you have any motor vehicles which need to be covered under your church insurance? If yes, we will provide you with a schedule for details of vehicles, including Year, Make, Model and Registration. The following Professional Indemnity and Associations Liability are Claims Made policies. A Claims Made policy covers you for claims or circumstances, which may give rise to a claim, reported to the Insurer while the policy is in force. If you become aware of a claim or circumstance that could give rise to a claim in the future, you need to notify us in writing immediately, so we can notify your insurer on your behalf. If you become aware of a claim/circumstance and you do not notify the insurer during the policy period, you could be left uninsured or facing a reduced payout from your insurer in respect of that claim or any future claim. Once the policy has expired you are not covered, except for claims and circumstances notified to the Insurers before expiry. Section F. Professional Indemnity 1. What limit of cover is required? 1 million 2 million 5 million Other (Please indicate limit required): Section G. Counselling 1. How many counsellors are there in your organisation? (Other than credentialed pastors.) Paid Unpaid Full time Part Time 2. Do any counsellors have individual cover for Professional Indemnity? 6 of 9

7 Section H. Associations Liability (Formerly offered as Directors & Officers Liability) 1. What limit of cover is required? 1 million 2 million 5 million Other (Please indicate limit required): 2. Please give details of any outside Directorships which are held at the request of the Organisation (Minority Interest already held). Individual External Company Position 3. Do you require Insolvency cover? If yes, you must enclose a copy of your most recent audited Financial Statements. Additional premium will be charged for this extension upon receipt of proposal form. 4. Is your income above 3 million? If yes, you must enclose a copy of your most recent audited Financial Statements. Premiums will be calculated upon receipt of proposal form. 5. Claims/Circumstances (Please only complete if you require PI or Associations Liability Cover) a) Have any claims ever been made against you, your predecessors in business or any of the present or past Pastors/Counsellors/Teachers? b) Are you aware, after enquiry, of any circumstances which may result in any claims against you, your predecessors in business or any of the present or past Pastors/Counsellors/Teachers? c) Has any insurer ever declined, cancelled, or imposed special conditions in relation to liability insurance? d) Have you or any Pastors/Counsellors/Teachers or staff members ever been subject to disciplinary proceedings for misconduct in a professional respect? If you have answered yes to question 5a, b, c and/or d, please provide full details on a separate sheet. Section I. Claims History 1. Have you had any claims in the last 3 years in any of the following areas? a) Property loss or damage b) Liability c) Personal Accident If yes to any of the above, please provide details: 2. Have you ever had any: a) Insurance cancelled or declined? b) Renewal refused by an insurer? c) Special conditions imposed? d) n-standard excess imposed? If yes to any of the above, please provide details: 7 of 9

8 Section I. Claims History (cont.) 3. Have you, any Director, Partner or Associate ever: a) Been declared bankrupt? b) Had bankruptcy proceedings lodged? c) Been found guilty of any criminal offence? If yes to any of the above, please provide details: Section J. Declaration Privacy The security and confidentiality of client information is of paramount importance to us. Under no circumstances is client information accessible in public areas. Our staff are trained to ensure that confidential information is not disclosed to outside parties unless authorised to do so. Duty of Disclosure Under insurance law, you are required to tell us anything you know that may affect our decision to accept your insurance. You must tell us these things before we issue cover, and whenever you renew, extend, vary or reinstate a policy of insurance. If you do not disclose all relevant information, or if you misrepresent the facts, then the insurer may be entitled to cancel the policy, reduce or refuse to pay a claim or treat the policy as having never existed. Examples of the type of information required for a church/religious organisation s insurance policy are: Change in use of buildings, substantial changes to numbers of people ministered to, changes in activity that increase risk (ie. high risk youth activities, counselling services, Work For The Dole, major events), etc. Declaration I/We have read and understand the important facts and duty of disclosure which has been provided, and I/we understand that no insurance is in force until such time as the insurer has confirmed acceptance of the proposed insurance. I/we agree to authorise ACS Insurance Services to obtain from other insurers or an insurance or credit reference bureau any information relating to this insurance and any other insurance held by me/us now or in the past including claims under those insurances. Signature of Insured X Date (DD/MM/YYYY) / / Full Name Position Held By ticking this box I agree to receive the relevant Product Disclosure Statements (PDSs), FSG and other disclosure information about my policies electronically. Checklist - Have you attached all the relevant documents? Completed and signed proposal form A copy of your most recent valuation (Section B, 2) A copy of your asbestos register & remedial plans (Section B, 2g) A copy of your most recent audited Financial Statements (Section H, 3, 4) Full details of claims/circumstances related to PI or Associations Liability Cover, if you answered yes (Section H, 5a, 5b, 5c, 5d) Please send completed Church Insurance Proposal (including any attachments) to ACS Insurance Services: E [email protected] T F PO Box 346, Camberwell VIC of 9

9 Additional Information Please fill in the table below if you require more space than is available on the main Proposal form. Section Item(s) Further Details 9 of 9

10 ACS Financial Pty Ltd ACN AFSL