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ASSOCIATION LIABILITY (please complete if you are
applying for this cover)
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Required Total Sum Insured
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$1,000,000
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$2,000,000
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$5,000,000
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$10,000,000
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Directors and Officers cover
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Has any director or executive officer of the Association/Organisation been declared
bankrupt or entered into a deed of assignment, composition or a scheme of arrangement
with creditors?
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No
YesIf 'Yes', please provide details
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Financial Statements
As part of this proposal please attach the most recent Audited Financial Statements
(include balance sheet and income statement).
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Is there any subsequent information of a material nature not disclosed in the attached
financial statements that could affect the financial position, capital structure
or operation of the Association/Organisation?
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No
YesIf 'Yes', please provide details
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Professional Indemnity cover
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Nature of Business
State fully the nature of any professional services offered by or on behalf of the
Association/Organisation. (Please provide copies of any brochures or other documentation
which may assist us in gaining a better appreciation of the risk being proposed).
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Please tick Yes or No and give details as requested below
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Does the Association/Organisation:
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No
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Yes
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Provide legal, financial, investment or environmental advice?
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Engage in any form of medical treatment, medical advice or scientific or medical
research?
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Provide any web hosting or act as an internet service provider?
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Provide computer or information services or web sites with chat lines or bulletin
boards or discussion areas where input can be posted by the public at large?
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Promote or provide any form of insurance to Your members or act as insurance agent?
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Engage in the manufacture, sale or distribution of any product or process or patented
production process?
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If "Yes" to any of the above, please provide details on a separate sheet.
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Employment Practices cover
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Please state the number of employees in the following salary ranges:
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$0 - $35,000
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$35,001 - $100,000
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over $100,000
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Did You initiate any termination(s) within the last 2 years?
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No
Yes
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If 'yes' please state the reason for the termination (s) and the number of full-time
and part-time employees terminated.
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Please state the number of staff turnover for the last 2 years.
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Are written policies in place regarding the following?
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Equal opportunity
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No
Yes
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Anti-sexual harassment
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No
Yes
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Discrimination
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No
Yes
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Legal procedures to be followed before termination of employment
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No
Yes
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Fidelity Cover
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Have You sustained any loss through fraud or dishonesty of any employee?
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No
Yes
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Are all cheques required to be signed by at least two different authorised signatures?
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No
Yes
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Do You operate a trust account?
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No
Yes
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If 'yes', do You employ the services of an independent and qualified accountant
to audit Your trust account?
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No
Yes
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Have You ever received a tax audit advice from the Australian Taxation Office?
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No
Yes
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Do You employ the services of an independent accountant?
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No
Yes
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Association Liability - Claims and Circumstances
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At any time in the past, has any claim been made against the Association/Organisation
or any Office Bearers, Executive Staff, Sub-committee members, employees of the
Association/Organisation?
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No
Yes
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If 'Yes', please provide details.
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Are there any circumstances not already notified to insurers which may give rise
to a claim against the Corporation, or any Office Bearer, Executive Staff, Sub-committee
members, employees of the Association/Organisation?
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No
Yes
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If 'Yes', please provide details.
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If insurance similar to that now proposed had been, or were now in effect, would
any claim which had been made, or which is now pending against the Association/Organisation
or any person proposed for insurance, have fallen within the scope of such insurance?
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No
Yes
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If 'Yes', please provide details.
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Is any person proposed for insurance aware, after enquiry, of any circumstances
or incident which he/she believes might give rise to any future claim that would
fall within the scope of such insurance?
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No
Yes
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If 'Yes', please provide details.
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Has the Association/Organisation or any person proposed for insurance ever had similar
insurance cancelled or declined to renew, or had special terms imposed in relation
to this type of insurance?
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No
Yes
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If 'Yes', please provide details.
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Has there been, or is there now pending, any prosecution of the Association/Organisation
or its subsidiaries under the Corporations Law, Trade Practices Act, or any other
statute?
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No
Yes
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If 'Yes', please provide details.
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