Management Liability Proposal Form

Management Liability Questionnaire

Name of Insured: *
Contact Phone Number: *
Email: *
Name of person completing application *
Position within organisation *
Does the person completing the proposal have authority and sufficient knowledge to answer questions relating to the business operation and insurance history? *

NOTE: If answer is NO, please ensure proposal is counter signed as being true and correct by a principal or officer with sufficient information

Annual Gross Turnover for the last financial year

Year *
Turnover *
Occupation of the Insured *

Break up of turnover by region

NSW *
TAS *
ACT *
VIC *
SA *
WA *
QLD *
OS *

2. Limits and Coverage Parts

Please choose either a Combined Limit of Liability across all Coverage Parts (A), or Seperate Limits and the Coverage Parts required (B).

A) COMBINED LIMIT OPTION

Which limit of indemnity would you like a quote for? *

B) SEPARATE LIMITS

Please choose which Coverage Parts you require by entering the limit of indemnity in the coverage part/s you require (Minimum of two coverage parts must be taken)

Directors and Officers Liability
Employment Practices Liability
Statutory Liability
Company Expenses

3. Business Information

How many permanent employees do you have in total? *
How many casuals, temps, or other employees do you have in total? *
In the last two years, how many permanent employees in total have been retrenched, dismissed or resigned?
Have you had any employment practices issues in the past 5 years? *
If yes, please provide details
What type of company are you (eg private, not for profit etc)? *
How long have you been in operation? *
Do you require cover for insolvency? If yes, *
1) Have you got assets exceeding your liabilities? *
ii) Have you returned a trading profit in each of the last 2 years? *
Have you evern been involved in any merger or acquisition in the last 3 years? *
Without review or approval from at least one other person, can any one individual sign cheques, issue electronic funds transfer, prepare cheque requisitions, handle bank deposits, reconcile bank statements or refund monies? *
If yes, please provide full details
Have you been the subject of any formal investigations or audits by any regulatory or governmental body? *
If yes, please provide full details.
Have you got Occupational Health and Safety procedures in place? *

4. Claims Information

For the last (3) years, have there been any claims made against the Company, or it’s directors or employees which may have been covered under this Policy if it were in force? If Yes, please provide details using a separate attachment *
Has any director or officer of the Company ever had proceedings (civil or criminal) instigated against them alleging misconduct or breaches of the law in their capacity as director or officer of a company? If Yes, please provide details using a separate attachment *
Are any directors or employees of the Company aware of any facts that might give rise to a claim being made against the Company, or it’s directors or employees which may be covered under this Policy if it commences? If Yes, please provide details using a separate attachment(1) *
Have you ever sustained any loss through the fraud or dishonesty of any employee or director? If yes, please provide details using a separate attachment *
Are any directors or employees of the Company aware of any facts that might give rise to a claim being made against the Company, or it’s directors or employees which may be covered under this Policy if it commences? If Yes, please provide details using a separate attachment *

Please upload any supporting attachments below

Attachment 1
Attachment 2
Attachment 3
Word Verification:

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We collect personal information from you and others so we can provide insurance, policy administration and claims handling and for associated reasons such as market or customer satisfaction research and product development.
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