Management Liability Form 1 Applicant & Business 2 Financial 3 Employees 4 Security & Risk 5 Claims & Indemnity Section 1 – Details of applicant Insured Name Address of head office Web Address Date established (dd/mm/yy) Country / State of Registration ABN / ACN Telephone No. Address of all other locations (if any) from which the Insured operates Section 2 – History of the company If any of the answers to the following questions are YES, please provide full details in the space provided at the end of the section. If there is insufficient space, provide details on a separate page and attach to the Proposal. 1. Does the Company have any securities listed on any stock exchange such as the ASX or CxA? YesNo 2. Has the Company made or are there any pending acquisitions, mergers, divestments or material capital raisings in either the past or following twelve months? YesNo 3. During the last three (3) years, has the Company changed its external auditors and/or legal advisors? YesNo 4. Is the Company involved in any business activities or does it hold any assets in the USA &/or Canada? YesNo 5. Does any shareholder own more than 50% of the Company’s Ordinary Share Capital? YesNo 6. Within the past five (5) years has the Company or its Directors or Officers disclosed confidential information to any third party including potential business partners? YesNo 7. Has any employee that has had access to the Company’s confidential information left your employment within the past three (3) years? YesNo Previous Next Section 3 - Financial information 1. Please provide the Company’s Gross Consolidated Turnover (based on the average of last two (2) years): AUD$ 2. Please provide the Company’s Gross Consolidated Total Assets (last actual financial year): AUD$ 3. Please provide the Company’s Gross Consolidated Net Assets (last actual financial year): AUD$ 4. In the past three (3) years, has there been (or is there now proposed) any change in the financial position or capital structure that may materially affect the financial performance of the Company? YesNo 5. Is any Director or Officer of the Company aware of any facts or circumstances that may affect the ability of the Company to meet its debts as and when they fall due? YesNo The Policy contains an Insolvency Exclusion. On receipt and review of audited financial statements we can consider removing this exclusion. 6. Do you have a current Management Liability Insurance Policy in place? YesNo If YES, please provide full details: Name of the Insurer: Limit of Indemnity: Deductible: Expiry Date of the Policy Period: Retroactive Date: 7. Does the Company hold any of the following policies? a. Statutory Liability YesNo b. Legal Expenses YesNo c. Workers Compensation YesNo d. Employers Liability YesNo e. Tax Audit Expenses YesNo If YES, please provide full details: Name of the Insurer: Limit of Indemnity: Deductible: Type of Policy: Expiry Date of the Policy: Retroactive Date: 8. In respect of turnover for the last financial year, please provide a breakdown by State: NSW % ACT % QLD % VIC % TAS % SA % WA % NT % O/S % Total 100% Previous Next Section 4 - About the employees 1. Please provide the total number of your current employees: Type of Employee Number Board members, Directors, Partners & Officers Full time employees excluding the above Part-time employees Casual employees Independent contractors Voluntary workers Total 2. Do you anticipate a significant change to the number of employees in the next twelve (12) months? YesNo 3. Is the Company or any of its subsidiaries undergoing any employee redundancies, layoffs, or early retirement (including those resulting from any type of company restructure, acquisitions, divestment, office or plant closure) in the next twelve (12) months? YesNo 4. Does the Company have written employment procedures (for example an Employee Handbook) that are made available to each employee, and does the Company adhere to these procedures at all times? YesNo 5. Please complete the below table, based on your current year estimates: Annual Salary Bracket Number of Employees $0 - $50,000 $50,000 - $100,000 $100,000 - $250,000 > $250,000 6. Are all of your employees engaged under a written contract of employment? YesNo 7. Are decisions regarding redundancies, layoffs or negative performance evaluation always subject to prior review by the: a. Company’s Human Resources or equivalent? YesNo b. Internal Legal Department? YesNo c. External Legal Counsel? YesNo Previous Next Section 5 - Employee theft 1. Do you ensure the following operations are always segregated so that no one person can control any function from start to finish without referral to another individual: a. signing cheques or authorising payments above $1,000 YesNo b. issuing funds transfer instructions YesNo c. amending funds transfer procedures YesNo d. opening new bank or supplier accounts YesNo e. refund of monies or return of goods above $1,000 YesNo 2. Do you always ensure bank statements are independently reconciled by persons not authorised to deposit or withdraw funds or to issue funds transfer instructions? YesNo 3. Is an independent physical count of stock, raw materials, work in progress and finished goods undertaken and is this count reconciled against stock levels? YesNo a. How frequently? b. Were any discrepancies discovered during last stock check? YesNo 4. Do you always ensure wages or salaries are independently checked against personnel records for unusual or excessive payments? YesNo 5. Are passwords automatically withdrawn when staff members leave your employment? YesNo 6. Do you maintain an approved suppliers list? YesNo 7. Are suppliers, service providers and outsourcing companies: a. vetted for competency, financial stability and honesty before being approved? YesNo b. appointed under written contract? YesNo Section 6 – Social Engineering and Cyber Fraud 1. Does the Insured wish to include cover for Social Engineering, Phishing & Cyber Fraud for an additional premium up to 10%? If NO, proceed to Section 8 YesNo 2. When creating or amending supplier and customer payment details, does the Insured independently verify the details with a known contact by phone or in person? YesNo 3. Does the Insured maintain procedures for the provision of written training materials to all Employees regarding the dangers of Social Engineering Fraud, Phishing, and Cyber Fraud which incorporate regular review? YesNo 4. Does the Insured implement procedures for accessing any and all online financial accounts and banking platforms requiring either: a. two factor authentication YesNo b. passwords changed at least every 45 days YesNo c. long passwords of 12+ chars or ≥3 special chars YesNo 5. For Sole Traders and Partnerships only, does the Insured ensure that at least two members of staff authorise any transfer of funds, signing of cheques (above $10,000) and the issuance of instructions for the disbursement of assets, funds or investments? YesNo Note: If the Insured is comprised of only two (2) staff (including all principals, partners, directors, and employees full time, part time and casual staff, interns and volunteers) and only Directors hold authority to approve any transfer of funds, signing of cheques (above $10,000) and issuance of instructions for the disbursements of assets, funds or investments, OR if comprised of only one (1) staff, answer Yes to this question. Section 7 – Risk management 1. Does the Company have a current manual for Occupational Health & Safety Procedures and Environmental Protection Procedures that is distributed to all workers? YesNo If NO, please provide full details: 2. Are all employees appropriately trained and inducted at the outset of their employment with the Company? YesNo If NO, please provide full details: 3. Does the Company have any workers that are engaged in any hazardous manual activities (including work in confined spaces, abrasive blasting, electrical work, diving and other high risk activities)? YesNo If YES, please provide full details: Previous Next Section 8 – Claims details 1. After enquiry, is the proposed Insured aware of any facts or circumstances which might afford valid grounds for any future claim(s) or which would indicate the probability of any such claim(s) under any section of the cover for which it has applied? YesNo 2. Within the last three (3) years, has the proposed Insured been the subject of any complaint, suit, inquiry or notice of a hearing from any State, Territory or Federal regulatory body, or any other party? YesNo 3. Within the last three (3) years, has the proposed Insured discovered any losses from employee dishonesty, burglary, robbery, disappearances, destruction or forgery? YesNo 4. Has the proposed Insured been declined, had cancelled or non-renewed any insurance policies for any of the coverages for which it has applied? YesNo 5. Have any claims ever been made against the Company or any of its Directors, Officers or employees for wrongful termination, discrimination intimidation or sexual harassment? YesNo 6. In the past five (5) years has the proposed Insured had any fine or penalty imposed by, or been served an infringement, improvement or prohibition notice or enforcement order by Federal, State, Local Government or Regulatory Authority? YesNo 7. In the past five (5) years has the proposed Insured had a Workplace or Environmental incident (including a workplace fatality, serious injury or dangerous incident) that either required notification to, or warranted investigation by, a Regulatory Authority or a compulsory requirement to attend any hearing, inquiry, prosecution or other commission? YesNo 8. Has the Company ever had any Insurer decline a proposal or cancel or refuse Management Liability Insurance? YesNo If insufficient space, please provide details on a separate page and attach to this Proposal. Section 9 - Indemnity limit Please select the amount of Indemnity required: $1,000,000$2,000,000$5,000,000$10,000,000 Other: Declaration Signing this Proposal Form does not bind the proposer or the Insurer to complete this insurance. The undersigned declares that the statement and particulars in this Proposal Form are true and that no material facts have been misstated or suppressed after enquiry. The undersigned agrees that should any of the information given by us alter between the date of this proposal and the inception date of the insurance to which this proposal relates, the undersigned will give immediate notice thereof. The undersigned agrees that the Underwriters may use and disclose our personal information in accordance with the Privacy Collection Statement at the beginning of this proposal. The undersigned acknowledges that they have read the policy wording and associated endorsements and are satisfied with the coverage provided, including the limitations and restrictions on coverage. The undersigned agrees that this proposal, together with any other information supplied by us shall form the basis of any contract of insurance effected thereon. To be signed by the Insured for whom this insurance is intended for Full name: Position: Signature: Date: It is important the undersigned of the declaration above is fully aware of the scope of this insurance so that these questions can be answered correctly. If in doubt, please contact the broker or agent, since non-disclosure may affect an Insured's right of recovery under the policy. DUAL Australia recommends that you keep a record of all information supplied for the purpose of entering into an insurance contract (including copies of this proposal form and correspondence). Previous Next
