DOMESTIC BUILDING INSURANCE APPLICATION FOR ELIGIBILITY REVIEW

DOMESTIC BUILDING INSURANCE APPLICATION FOR ELIGIBILITY REVIEW INSURANCE BROKER RETURN COMPLETED FORMS TO HOME WARRANTY INSURANCE DIVISION: Master Builders Queensland Insurance Services A Divisin f Queensland Master Builders Assciatin ABN 96 641 989 386 AFS Licence 246834 Master Builders Huse, 18 Central Park Avenue, Ashmre Queensland 4214 Telephne 1300 13 13 24 Facsimile 1300 13 13 28 warrantyassessment@masterbuilders.asn.au www.masterbuilderswarranty.cm.au

FROM 1 JULY 2015, THIS FORM MUST BE USED. NO OTHER VERSION WILL BE ACCEPTED. QBE Insurance (Australia) Limited 628 BOURKE STREET, MELBOURNE VIC 3000 Phne: (03) 9246 2666 Fax: (03) 9246 2611 ABN: 78 003 191 035 AFS Licence N: 239545 APPLICATION TO REVIEW ELIGIBILITY Dmestic Building Insurance ABOUT THIS FORM This frm will help us decide if the Applicant is eligible fr the renewal f their eligibility t purchase dmestic building insurance cver. If we decide the Applicant is eligible fr cver, we will rely n the infrmatin in this frm. Yu must therefre ensure yu answer all questins truthfully. Wh shuld cmplete this frm? This frm shuld be cmpleted fr businesses with current eligibility with QBE/VMIA in circumstances where: The Applicant wishes t increase the annual limit QBE/VMIA initiates a review fr any reasn. ELIGIBILITY WITH QBE/VMIA, WITH ADDITIONAL COVER FROM 1 JULY 2015 The insurance being applied fr is issued by QBE Insurance (Australia) Limited (QBE) as agent fr the Victrian Managed Insurance Authrity (VMIA) in accrdance with the Ministerial Order fr Dmestic Building Insurance issued under sectin 135 f the Building Act 1993 (Vic), with additinal cver if the Applicant fails t cmply with a Tribunal r Curt Order fr certificates f insurance issued n r after 1 July 2015. The VMIA is a statutry crpratin and is the insurer. INFORMATION DISCLOSED IN THIS FORM AND YOUR PRIVACY Bth QBE and the VMIA are cmmitted t safeguarding yur privacy and the cnfidentiality f yur persnal infrmatin. We will nly cllect persnal infrmatin frm yu r abut yu which is relevant t prcessing and assessing this applicatin, administering any dmestic building insurance plicies which may subsequently be issued, including any claims under such plicies, and any recveries and use it in a way that yu wuld expect. The persnal infrmatin cllected may include persnal details, cnstructin details, financial infrmatin and arrangements. Withut this persnal infrmatin we may nt be able t prcess this applicatin r issue insurance cver. By prviding this persnal infrmatin t us, yu cnsent t us disclsing yur persnal infrmatin t: insurance intermediaries insurance reference bureaus credit reference agencies ur advisers the Victrian Building Authrity r ther authrities established t regulate r reprt n the building industry thse invlved in the claims handling prcess (including assessrs and investigatrs) fr the purpse f assisting us and them in prviding relevant reprting, regulatin, services and prducts, r fr the purpses f litigatin. Yu als cnsent t us disclsing yur persnal infrmatin t: the wners f any building wrk undertaken by the Applicant which is insured by us family members r agents authrised by yu rganisatins which cnduct custmer service surveys n ur behalf peple making enquiries as t whether a nminated builder is eligible fr dmestic building insurance peple making enquiries fr details f any dmestic building insurance issued in respect f a nminated prperty. Such persnal infrmatin is limited t: plicy number plicy inceptin date prperty address name f builder whether a claim has been made the amunt f any indemnity remaining under the plicy. ACCESS TO YOUR PERSONAL INFORMATION YOUR DUTY OF DISCLOSURE Yu can request access t the persnal infrmatin we hld abut yu by cntacting: QBE Insurance (Australia) Limited 628 Burke Street Melburne Victria 3000 Phne: 03 9246 2666 VMIA PO Bx 18409 Cllins St East Victria 8003 Phne: 1300 363 424 We require yu t disclse t us every matter that yu knw, r culd reasnably be expected t knw, is relevant t ur decisin whether t issue insurance t the Applicant and n what terms. We require yu t disclse thse matters t us befre we renew, extend, vary r reinstate the Applicant s eligibility r issue a certificate f insurance. Yu are nt, hwever, required t disclse any matter that diminishes the risk t us that is f cmmn knwledge, that we knw r in the rdinary curse f ur business ught t knw r any matter which we waive. We will rely n the infrmatin that yu prvide t us in determining whether t cntinue t prvide insurance t the Applicant and n what terms. DOMESTIC BUILDING INSURANCE QM3264 06 15 Victrian Managed Insurance Authrity ABN 39 682 497 841 PO Bx 18409 Cllins St East Victria 8003 P: 1300 363 424 F: 03 9270 6949 www.dbi.vmia.vic.gv.au Page 1 f 14

Plicy number: SECTION 1. ABOUT THE APPLICANT PLEASE USE CAPITAL LETTERS. A B C Nte: yu is the persn signing the frm. The entity fr which cver is sught is the Applicant. Where the Applicant is a partnership r cmpany, this sectin must be cmpleted by each partner r directr. What is the legal name f the building entity (business) fr which cver is sught (Applicant)? ACN: ABN: Business address: State: Pstcde: Cntact persn: Business telephne number: Mbile number: Facsimile number: Email: Business type (select ne): Sle trader Partnership Cmpany Name f Registered Building Practitiner: Building Practitiners Registratin number: Anniversary date: Is the Applicant a subsidiary f anther entity? N Yes Please prvide name and ACN f parent cmpany: Des the Applicant have subsidiary cmpanies? N Yes Please prvide name/s and ABN/ACN f subsidiary cmpanies: DOMESTIC BUILDING INSURANCE QM3264 06 15 Page 2 f 10

SECTION 2. HISTORY AND BACKGROUND Has any business in which yu are, r have been invlved, ever been: placed int external administratin, liquidatin, receivership r entered int a scheme f arrangement (frmal r infrmal) t repay utstanding creditrs? subject t any legal judgement? invlved in legal prceeding? N Yes Date ccurred: Name f business: Name f Administratr/Curt/Tribunal: Explanatin (please attach relevant dcument) Have/are yu: ever been declared a bankrupt? ever been the subject f a legal judgement? currently invlved in any legal prceedings? N Yes Date ccurred: ever entered int a scheme f arrangement, cmpsitin, debt agreement r a persnal inslvency agreement under the Bankruptcy Act? Name f persn: Name f Administratr/Curt/Tribunal: Explanatin (please attach relevant dcument) D yu r any business yu are invlved in currently have eligibility fr dmestic building insurance with anther insurer? N Yes Insurer name: Name f insured business: Expiry date: Are yu aware f any circumstances that may give rise t a claim under any dmestic building insurance plicy which insures building wrk undertaken by yu r a business yu have been invlved in, r has a claim ever been paid under such a plicy? N Yes Insurer name: Name f business: Prperty address: Owner s name: Date f claim r date yu became aware f a circumstance that may give rise t a claim: DOMESTIC BUILDING INSURANCE QM3264 06 15 Page 3 f 10

SECTION 2 CONTINUED Have yu r any business in which yu have been invlved ever been rdered by a curt r a tribunal t make a payment fr any incmplete r defective building wrks r been rdered t rectify any building wrks? N Yes Curt/Tribunal: Name f business: Owner s name: Prperty address: Have yu r any business in which yu have been invlved ever been disciplined by any regulatry authrity in relatin t building wrk which yu r that business has undertaken? N Yes Name f Authrity: Name f business: Date rder/s made: Descriptin f the rder/s: SECTION 3. ANNUAL CONSTRUCTION LIMITS REQUIRED Existing eligibility turnver limit: Required turnver limit (next 12 mnths): Please nte that ur underwriters will undertake an assessment f the Applicant s current financial psitin and the Applicant will need t submit the fllwing infrmatin/dcumentatin: Full and final financial statements (prfit and lss statement with trading statement, balance sheet and ntes t accunts) fr the last 2 full financial years as prepared by the Applicant s external accuntant and signed by the Applicant as being true and crrect. If the current year financial statements are lder than (6) six mnths, interim financial statements are required (internally prepared accunts are acceptable prviding they are signed by the applicant/directrs r external accuntant as being true and crrect and are prepared utilising a recgnised accunting package). Wrks categry Maximum jb value Number f jbs Eligibility amunt Single dwellings Alteratins nn-structural Alteratins structural Kitchens Bathrms Swimming pls Carprts/garages Multi-unit DOMESTIC BUILDING INSURANCE QM3264 06 15 Page 4 f 10

SECTION 4. STATEMENT OF PERSONAL ASSETS AND LIABILITIES This sectin must be cmpleted by: If the Applicant is an individual, that individual If the Applicant is a partnership, each partner f that partnership If the Applicant is a cmpany, each directr f that cmpany Please cpy and prvide fr each directr r partner. Name f sle trader/partner/directr: Date f birth: Building Practitiners Registratin number (if applicable): Residential address: State: Pstcde: Email address: Telephne number: Assets Value Liabilities Amunt PROPERTY Principal residence at: Mrtgage lan with: Other prperty at: Mrtgage lan with: MOTOR VEHICLES Year Make Mdel Vehicle finance with: INVESTMENTS OTHER LOANS OTHER Cash at bank: Credit cards: Wrk in prgress (sle traders nly): Trade receivables (sle traders nly): Overdraft (sle traders nly): Trade Creditrs (sle traders nly): DOMESTIC BUILDING INSURANCE QM3264 06 15 Page 5 f 10

SECTION 5. FINANCIAL INFORMATION, HISTORY AND BACKGROUND OF APPLICANT This sectin is abut yur business (the Applicant). Where the Applicant is a partnership r cmpany, this sectin must be acknwledged as being true and crrect by each partner r directr f the cmpany. When did the Applicant cmmence trading? What jb csting system des the Applicant use? Manual Custm Standard industry Hw ften des the Applicant prduce financial reprts? Details f the Applicant s external accuntants Business name: Accuntant name: Phne number: Email address: Average building cycle (based n the last 12 mnths) Number f weeks frm signing f cntract t cmmencement f cnstructin n site: Number f weeks frm cmmencement f cnstructin t satisfactry cmpletin/handver t the hmewner: Three largest prjects (by cntract value) in the last 3 years: Jb descriptin (e.g Cnstructin f 20-unit dwelling) Cntract value Applicant s rle n site Year cmpleted DOMESTIC BUILDING INSURANCE QM3264 06 15 Page 6 f 10

SECTION 5 CONTINUED Current wrking capital psitin ( Infrmatin and balances must nt be mre than 90 days ld): Current number f jbs Ttal Value Current Assets Balances as at / / Cash at bank Trade debtrs* Agreed terms Days Wrk-in-prgress (value f wrk cmpleted but nt yet inviced) Other* (please prvide details) (A) Ttal Current Assets Current Liabilities Overdraft Include credit limit Trade creditrs Agreed terms Days Suppliers* Agreed terms Days Shrt term lans Directrs lans Bank bills Taxatin GST Other* (please prvide details) (L) Ttal Current Liabilities Net Wrking Capital Psitin (NWC) = (A) minus (L) *D nt include intercmpany/related party lans DECLARATION I/We cnfirm the abve infrmatin is true and crrect Signature (Directr r Partner): / / Name: Psitin/Title: DECLARATION I/We cnfirm the abve infrmatin is true and crrect Signature (Directr r Partner): / / Name: Psitin/Title: DECLARATION I/We cnfirm the abve infrmatin is true and crrect Signature (Directr r Partner): / / Name: Psitin/Title: DOMESTIC BUILDING INSURANCE QM3264 06 15 Page 7 f 10

SECTION 6. DOMESTIC BUILDING INSURANCE WORK IN PROGRESS STATUS REPORT Needs t be cmpleted fr all prjects under cnstructin r where depsits have been taken (please cpy this page and attach if additinal space is required) Name f the Applicant: Building registratin number: Date cntract entered int (dd/mm/yyyy) Site address (if Multiple dwellings are being cnstructed n the ne site, please list the site address nce and shw the number f units) Cntract Value (including GST) Date wrk cmmenced n site (dd/mm/yyyy) Insured by Current stage f cmpletin (depsit, Base, Frame, Lck-up, Fit-ut) Estimated cst t cmplete Estimated cmpletin date (dd/mm/yyyy) DOMESTIC BUILDING INSURANCE QM3264 06 15 Page 8 f 10

SECTION 7. INFORMATION CHECKLIST (Please tick all that apply) INFORMATION THAT YOU MUST SUPPLY WITH THIS APPLICATION Fr sle traders/partnerships: Prfit and lss statement including trading accunt fr the last 2 financial years (a cpy f the full tax return as submitted t the ATO will suffice). Fr cmpanies: Full and final financial statements (prfit and lss statement, with trading statement, balance sheet and ntes t accunts) fr the last 2 financial years (cmpanies). These must be signed by each f the directrs f the cmpany as being true and crrect. If the current year financial statements are lder than six mnths, a cpy f the interim financial statements are required (internally prepared accunts are acceptable prviding they are signed by the directrs/partners r external accuntant as being true and crrect and are prepared using a recgnised accunting package). The requirement f Cash Flw Frecasts, Budgets and/r cnfirmatin f financing arrangements will be at the discretin f underwriters. Grup structures If the Applicant is a subsidiary f anther entity r part f a larger grup structure then financial statements (prfit and lss statement with trading statement, balance sheet and ntes t accunts) fr the last 2 financial years, as prepared by an external accuntant, are required fr each and every entity in the grup. Fr structures with related entity lans, an explanatin f the purpse, term and size f these facilities is required frm yur external accuntant. Fr ALL Applicants, please prvide (in additin t the abve) Cpy f Certificate f Business Registratin fr the Applicant. Cpy f trade assciatin membership. Cpy f the current registratin certificate fr each directr r partner f the Applicant which is a registered building practitiner, r if the Applicant is a sle trader, fr yu. Current warranty eligibility frm existing insurer (ther than QBE/VMIA). General technical references fr architect design and multi-unit prjects. Evidence f wnership fr all prperties listed in the statement f persnal assets and liabilities (Sectin 4). Is there any further infrmatin r matter f a material nature nt therwise disclsed in this applicatin that: culd significantly affect the financial psitin f yu r the Applicant? might influence QBE s acceptance f this applicatin n behalf f the VMIA r the terms upn which the applicatin is accepted? might influence QBE s decisin t issue dmestic building insurance n behalf f the VMIA t the Applicant? N Yes Please detail further infrmatin r relevant matters: DOMESTIC BUILDING INSURANCE QM3264 06 15 Page 9 f 10

SECTION 8. APPLICANT S DECLARATION COPY AND ATTACH AS REQUIRED This declaratin is t be signed by: The Applicant, if the Applicant is a sle trader Each partner, if the Applicant is a partnership Each directr, if the Applicant is a cmpany I acknwledge that:. QBE and the VMIA reserve the right t revke at any time eligibility granted t the Applicant t purchase dmestic building insurance. I agree that: If any f the infrmatin disclsed in this applicatin materially changes, I will ntify QBE immediately. In my persnal capacity and, where relevant, as agent fr the Applicant that I, and where relevant, the Applicant shall reimburse the VMIA any amunt that it pays in respect f a claim, and the VMIA is entitled t be subrgated t the rights f the wner and can bring a claim against the Applicant in the name f the wner r in its wn name t recver any amunts that it has paid in respect t the claim. Fr certificates f insurance issued n r after 1 July 2015, in additin t cver prvided in accrdance with the Ministerial Order, the wner is als entitled t make a claim if the Applicant fails t cmply with a Tribunal r Curt Order. I declare that: I have read and understd the Infrmatin disclsed in this frm and Yur Privacy statements n page 1 f this frm. The Applicant is currently slvent and can meet all f its financial bligatins as and when they fall due. All infrmatin given in this applicatin and any attachments is true and crrect. Authrity t release infrmatin I authrise QBE and the VMIA t give t, r btain frm, ther insurers r insurance reference bureaux, credit reprting agencies, their advisrs, the Victrian Building Authrity r ther authrities established t regulate r reprt n the building industry, thse invlved in the claims handling prcess (including assessrs and investigatrs) and thse invlved in any way in cnnectin with building wrk insured under any dmestic building insurance plicy issued as a result f this applicatin, including thse peple making enquiries as identified n page 1 f this frm, any infrmatin abut r cntained in this applicatin, any dmestic building insurance plicy subsequently issued, and any claims and recveries, including this cmpleted applicatin and my and the Applicant s insurance claims histry and credit histry. 1. Declared by: Fr and n behalf f: Psitin title: Signature: 2. Declared by: Fr and n behalf f: Psitin title: Signature: 3. Declared by: Fr and n behalf f: Psitin title: Signature: DOMESTIC BUILDING INSURANCE QM3264 06 15 Page 10 f 10