Allianz Global Corporate & Specialty Pacific Allianz Professional Indemnity Insurance Management Consultants Proposal Form
General Information The General Information set out below is provided for your (the Insured s) information only. It does not form part of the insurance contract with you, and is not part of the policy. othing contained in the General Information imposes contractual obligations on you, or creates contractual rights. These are contained in the policy and any endorsement. our Duty of Disclosure Before ou (the Insured) enter into the Policy with Us (the Insurer), the Insurance Contracts Act 1984 requires ou to disclose to Us every matter that you know or could reasonably be expected to know is relevant to Our decision whether and on what terms our application for insurance is acceptable and to calculate how much premium is required for our insurance. ou have the same duty to disclose those matters to Us before ou renew, extend, vary or reinstate the Policy. The duty applies until the Policy is entered into, or where relevant, renewed, extended, varied or reinstated (Relevant Time). If anything changes between the time ou provide answers or make disclosure and the Relevant Time, ou need to tell Us. What ou do not need to tell Us ou do not need to tell Us about any matter that: diminishes Our risk; is of common knowledge; We know or should know as an insurer; or We tell ou We do not need to know. What happens if the duty of disclosure is not complied with? If the duty of disclosure is not complied with We may cancel the Policy and/or reduce the amount We pay if ou make a claim. If fraud is involved, We may treat the Policy as if it never existed, and pay nothing. Claims Made This policy operates on a claims made and notified basis. This means that the policy covers you (the Insured) for claims made against you and notified to us (the Insurer) during the Period of Insurance. The policy does not provide cover in relation to Prior Claims/Circumstances (as set out in the relevant exclusion) nor in relation to acts, errors, omissions or other conduct which first takes place before the Retroactive Date of the policy (if such a date is specified). Where you give notice in writing to us of any facts that might give rise to a Claim against you as soon as reasonably practicable after you become aware of those facts but before the expiry of the period of insurance, you may have rights under Section 40(3) of the Insurance Contracts Act 1984 to be indemnified in respect of any Claim subsequently made against you arising from those facts notwithstanding that the Claim is made after the expiry of the period of insurance. Any such rights arise under the legislation only. The terms of the policy and the effect of the policy is that you are not covered for Claims made against you after the expiry of the period of insurance unless such Claim is made during the Discovery Period or under the Extension for Run-off After Transaction. Who does the duty apply to? The duty of disclosure applies to ou and everyone that is an insured under the Policy. If ou provide information for another insured, it is as if they provided it to Us.
General Insurance Code of Practice We (the Insurer) are a signatory to the General Insurance Code of Practice. The Code aims to raise standards of practice and service in the insurance industry. It: promotes better communication between insurers and customers which will lead to better public understanding of insurance to allow customers to make informed choices, and outlines good standards of practice and service to be met by insurers to enhance their reputation responding efficiently to their customers needs. Dispute Resolution Process We (the Insurer) will do everything possible to provide a quality service to you (the Insured). However, we recognise that occasionally there may be some aspect of our service or a decision we have made that you wish to query or draw to our attention. We have a Complaints and Dispute Resolution Procedure which undertakes to provide an answer to your complaint within fifteen (15) working days. If you would like to make a complaint or access our internal dispute resolution service please contact our nearest office and ask to speak to a dispute resolution specialist. Contact for assistance or confirmation of cover If you need to confirm any policy transaction or clarify any of the information contained in this policy document or if you have any other queries, please contact any of our offices or refer to our website at www.allianz.com.au. If this insurance has been issued through an insurance intermediary If your policy has been arranged through our agent, or a broker who is acting under an agency arrangement such as a binder with us, then they are acting as our agent and not as your agent. They will tell you when this is the case. for If our Policy has been arranged by a broker, other than a broker acting under such an agency arrangement with us, then the broker is acting as your agent. Where this Policy has been arranged through an intermediary a commission may be payable by us to them for arranging the insurance. Privacy otice At Allianz, we (the Insurer) give priority to protecting the privacy of your (the Insured s) personal information. We do this by handling personal information in a responsible manner and in accordance with the Privacy Act 1988 (Cth). How We Collect our Personal Information We usually collect your personal information from you or your agents. We may also collect it from our agents and service providers; other insurers and insurance reference bureaus; people who are involved in a claim or assist us in investigating or processing claims, including third parties claiming under your policy, witnesses and medical practitioners; third parties who may be arranging insurance cover for a group that you are a part of; law enforcement, dispute resolution, statutory and regulatory bodies; marketing lists and industry databases; and publicly available sources. Why We Collect our Personal Information We collect your personal information to enable us to provide our products and services, including to process and settle claims; offer our products and services and those of our related companies, brokers, intermediaries and business partners that may interest you; and conduct market or customer research to determine those products or services that may suit you. ou can choose not to receive product or service offerings from us (including product or service offerings from us on behalf of our brokers, intermediaries and/or our business partners) or our related companies by calling the Allianz Direct Marketing Privacy Service Line on 1300 360 529, EST 8am to 6pm Monday to Friday, or going to our website s Privacy section at www.allianz.com.au.
Who We Disclose our Personal Information To We may disclose your personal information to others with whom we have business arrangements for the purposes listed in the paragraph above or to enable them to offer their products and services to you. These parties may include insurers, intermediaries, reinsurers, insurance reference bureaus, related companies, our advisers, persons involved in claims, external claims data collectors and verifiers, parties that we have an insurance scheme in place with under which you purchased your policy (such as a financier or motor vehicle manufacturer and/or dealer). Disclosure may also be made to government, law enforcement, dispute resolution, statutory or regulatory bodies, or as required by law. Disclosure Overseas our personal information may be disclosed to other companies in the Allianz Group, business partners, reinsurers and service providers that may be located in Australia or overseas. The countries this information may be disclosed to will vary from time to time, but may include Canada, Germany, ew Zealand, United Kingdom, United States of America and other countries where the Allianz Group has a presence or engages subcontractors. We regularly review the security of our systems used for sending personal information overseas. Any information disclosed may only be used for the purposes of collection detailed above and system administration. Access to our Personal Information and Complaints ou may ask for access to the personal information we hold about you and seek correction by calling 1300 360 529 EST 8am 6pm, Monday to Friday. Our Privacy Policy contains details about how you may make a complaint about a breach of the privacy principles contained in the Privacy Act 1988 (Cth) and how we deal with complaints. Our Privacy Policy is available at www.allianz.com.au. Telephone Call Recording We may record incoming and/or outgoing telephone calls for training or verification purposes. Where we have recorded a telephone call, we can provide you with a copy at your request, where it is reasonable to do so.
Details of Proposer 1. a) Policyholder (Legal ame) b) Trading ame c) AB d) Contact Person e) If you intend to claim an Input Tax Credit for the premium paid for this policy, please specify the percentage of the premium you will be claiming: % f) For how many years has the Policyholder carried on business? 2. Policyholder s main office Street Address Suburb State Postcode Telephone Facsimile Website Email Address Details of the Business 3. Please provide the total amount of the firm s gross income/fees for the following periods: a) Previous financial year $ b) Current financial year $ c) Coming financial year (estimate) $ 4. Please state the percentage of gross income/fees for each of the activities set out below: Professional Services % of Current Income/Fees Strategic planning % Sales training and performance coaching % Process analysis % Technology implementation % Marketing, Advertising and Public Relations Consulting % Market Research % Other (please specify): % Total 100% Use a separate sheet of your letter head if insufficient room above 1
Claims Information 5. After enquiry of the Partners/Principals/Directors and employees, has there been or is there now pending a claim against the Policyholder, its Subsidiaries, it s predecessors in business or it s current or former Partners/ Principals/Directors or employees for a Civil Liability in the performance of the Policyholder s Professional Services? If es, please give details (use a separate sheet of your letter head if insufficient room below). 6. After enquiry of the Partners/Principals/Directors and employees is the Policyholder or any of its Subsidiaries aware of any circumstance or incident which may give rise to a claim against the Policyholder, its Subsidiaries or it s Partners/Principals/Directors or employees? If es, please give details (use a separate sheet of your letter head if insufficient room below). 7. After enquiry of the Partners/Principals/Directors and employees is the Policyholder or any of its Subsidiaries aware of any prosecution or investigation (actual or pending) of the Policyholder, any Subsidiary, or any Partner / Principal/Director or employees under any International, Commonwealth, State or Local statute, legislation, regulation or By Law? If es, please give details (use a separate sheet of your letter head if insufficient room below). 8. After enquiry of the Partners/Principals/Directors and employees, has the Policyholder, any Subsidiary or any Partner/Principal/Director or employee ever been subject to any disciplinary action, been fined or penalised, or been the subject of an inquiry investigating or alleging professional misconduct? If es, please give details (use a separate sheet of your letter head if insufficient room below). 2
Details of Current Insurance 9. As at today s date does the Policyholder have Professional Indemnity Insurance currently in force that has been paid for? If es, please state a) Insurer b) Indemnity Limit c) Expiry Date / / d) Retroactive Date 10. Has the Policyholder ever had any Insurer decline a proposal, imposed any special terms, cancelled or refused to renew a Professional Indemnity Insurance Policy? If es, please give details (use a separate sheet of your letter head if insufficient room below). 11. What limit(s) of liability does the Policyholder require quotations for? $1 million $2 million $5 million $10 million $15 million $20 million 12. What self insured retention is the Policyholder prepared to carry? $1,000 $2,000 $5,000 $10,000 Other: 3
Optional Extension for Breach of Privacy 13. a) Would the Policyholder like a quotation for Breach of Privacy coverage? b) If es has any Claim arising from a Breach Of Privacy ever been made against the Policyholder, its Subsidiaries or, after enquiry of the Partners/Principals/Directors, is the Policyholder or its Subsidiaries aware of any circumstances which may give rise to a Claim against the Policyholder, its Subsidiaries, or any its Partners/Principals/Directors or employees? If es, please supply the relevant details and advise what precautions have been taken to prevent a recurrence (use a separate sheet of your letter head if insufficient room below). Optional Extension for Employment Practices Liability 14. a) Would you like a quotation for Employment Practices Liability coverage? b) If es has any Claim arising from employment practices liability ever been made against the Policyholder, or any Subsidiary or, after enquiry of the Partners/Principals/Directors, is the Policyholder or any Subsidiary aware of any circumstances which may give rise to a Claim against the Policyholder or any Subsidiary or any its Partners/Principals/Directors or employees? If es, please supply the relevant details and advise what precautions have been taken to prevent a recurrence (use a separate sheet of your letter head if insufficient room below). Optional Extension for Officers Liability 15. a) Would you like a quotation for Officers Liability coverage? b) If es has any Claim arising from any directors or officers liability ever been made against any Partners/Principals/Directors or, after enquiry of the Partners/Principals/Directors, is the Policyholder or its Subsidiaries aware of any circumstances which may give rise to a Claim against any its Partners/Principals/Directors? If es, please supply the relevant details and advise what precautions have been taken to prevent a recurrence (use a separate sheet of your letter head if insufficient room below). 4
Optional Extension for Fidelity 16. a) Would the Policyholder like a quotation for Fidelity Insurance coverage? b) As at today s date, does the Policyholder currently have any fidelity guarantee/crime insurance? If es, a) Insurer b) Indemnity Limit c) Expiry Date / / d) Deductible c) Has the Policyholder or any Subsidiary ever sustained any loss through the fraud or dishonesty of any employee, or after enquiry of the Partners/Principals/Directors, is the Policyholder aware of any circumstances which may give rise to a loss against the Policyholder or any Subsidiary? If es, please supply the relevant details and advise what precautions have been taken to prevent a recurrence (use a separate sheet of your letter head if insufficient room below). d) Are monies, securities and/or negotiable instruments subject to control by a Partner, Principal or Director, or by at least two Employees? e) Is bank reconciliation carried out by someone not authorised to deposit into or withdraw from the bank accounts? f) When recruiting or promoting employees to positions or trust involving handling of stock, money, financial or treasury functions, does the Policyholder undertake independent checks in their employment history? Optional Extension for Workplace Statutory Liability 17. a) Would the Policyholder like a quotation for Workplace Statutory Liability coverage? b) If es has any Claim arising from workplace safety ever been made against the Policyholder or any Subsidiary or, after enquiry of the Partners/Principals/Directors, is the Policyholder or any Subsidiary aware of any circumstances which may give rise to a Claim against the Policyholder or any Subsidiary or any its Partners/Principals/Directors or employees? If es, please supply the relevant details and advise what precautions have been taken to prevent a recurrence (use a separate sheet of your letter head if insufficient room below). 5
Stamp Duty 18. For the purpose of calculating Stamp Duty please state the percentage of the Policyholder s gross income/fees that was earned in each state in the previous financial period: SW VIC QLD SA WA TAS ACT T Overseas* *If es to overseas operations,, please give details of the name of the client(s), the country they are located within and what service(s) are provided (use a separate sheet of your letter head if insufficient room below). Declaration Please ote: Signing the Declaration does not bind the proposer or the Insurer to complete this insurance. I declare that I have made all necessary inquiries into the accuracy of the responses given in this proposal and confirm that the statements and particulars given in this proposal are true and complete and that no material facts have been omitted, misstated or suppressed. I agree that should any of the information given by me alter between the date of this proposal and the inception date of the insurance to which this proposal relates, I will give immediate notice thereof to the insurer. I acknowledge receipt of the notices included in the cover sheet of this proposal and that I have read and understood the content of them. I confirm that I am authorised by the proposing Policyholder (and its partners/principals/directors if applicable) to complete this proposal form and to accept the quotation terms for this insurance on behalf of the Policyholder and its Subsidiaries (and its partners/principals/directors if applicable). ame: Title: Signature: Date: 6
Allianz Australia Insurance Limited 2 Market Street Sydney SW Australia Phone: +61 2 9390 6333 Fax: +61 2 9390 6488 www.allianz.com.au Disclaimer & Copyright Copyright 2014 Allianz Australia Ltd. All rights reserved. The material contained in this publication is designed to provide general information only. Whilst every effort has been made to ensure that the information provided is accurate, this information is provided without any representation or warranty of any kind about its accuracy and Allianz Australia Limited cannot be held responsible for any mistakes or omissions.