Professional Organiser & Concierge Proposal Form

Please select reason for completing form*

New Business Quote
Renewal

Standard coverage provided is $1M Professional Indemnity & $10M Broadform Liability. If higher amounts are required, please select options below:

$2M Professional Indemnity
$20M Broadform Liability

Name*

Full legal name of each natural person or incorporated body to be insured as well as any unincorporated business names.

Trading Name*

Has this person or entity ever changed or has any other business been purchased or has any merger or acquisition or consolidation ever taken place?*

Yes
No

Date Insured From*

Are you registered for GST purposes?*

Yes
No

ABN*

Contact/Business Owner Details

Name*

First Last

Phone*

Email Address*

Address*

Street Address City State Postcode

Qualifications*

DOB*

No. of Years Experience*

Business Details

Number of Employees*

Please enter a number from 0 to 99.

Number of Directors*

Please enter a number from 0 to 10.

Are you a member of a professional association or body?*

Yes
No

If yes, name of organisation

Describe your business activities in full detail*

If this is a renewal, have your business activities changed in the last 12 months?

Yes
No

If yes, please advise what these changes are.

Income

Estimated Gross Income for next 12 months*

Please show the % split between states below.

Queensland %

South Australia %

Victoria %

ACT %

NSW %

Western Australia %

Northern Territory %

Overseas

If overseas, please state countries

Your Duty of Disclosure

You have a duty under the Insurance Contracts Act 1984 (Cth) to disclose to the Insurer anything that You could reasonably be expected to know is relevant to their decision whether to accept the risk of insurance and if so, on what terms. You have the same duty to disclose those matters to the Insurer before You renew, extend, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of a matter: • that diminishes the risk to be undertaken by the Insurer; • that is of common knowledge; • that the Insurer knows or, in the ordinary course of business, ought to know; or • as to which compliance with Your duty is waived by the Insurer. The duty of disclosure applies to You and everyone insured under the contract of insurance. If You, or they, fail to comply with the duty of disclosure, the Insurer may reduce their liability under the contract in respect of a claim. If the non-disclosure is fraudulent, they may treat the Policy as if it never existed and pay nothing. It is important that all information provided in support of Your application for insurance is understood by You and is correct, as You will be bound by Your answers and by the information provided by You. If You do not understand any part of this notice, you should contact us. Your duty of disclosure continues after Your application for insurance has been completed up until the contract of insurance is entered into.

Disclosure Questions

Please answer the following questions in accordance with Your Duty of Disclosure above.

1. Are you aware of any fraud, dishonesty, bankruptcy or administration any past or present principal, partner, director or employee?*

Yes
No

2. Are you aware of any circumstance or incident which has or could result in any claim being made against your business, or any principal, partner, director or employee whilst in this or any other business?*

Yes
No

3. Has any claim been made against your business or any principal, partner, director or employee whilst in this or any other business?*

Yes
No

4. Are you aware of any criminal offences of any past or present principal, partner, director or employee?*

Yes
No

5. Have you ever had an insurer decline a proposal from you?*

Yes
No

6. Have you ever had an insurer impose special terms on a policy?*

Yes
No

Declaration

I / We declare and acknowledge that: • I / We have made due inquiry of the Applicant and its Principals, Partners, Directors and Employees concerning the questions asked within this Proposal and have authority to sign this Proposal on their behalf; • I / We have read and understood the Duty of Disclosure - Important Information Section of this Proposal; • The statements and particulars in this Proposal are true and correct; • This Proposal along with any other information supplied by Me /Us shall form the basis of any Policy entered into; • I / We understand that up until the Policy is entered into, We must notify any change in the matters disclosed in this Proposal; and • I / We will notify any material alteration to the matters disclosed in this Proposal occurring after completion of the Proposal.

*

Yes
No

Name

Date*