For "Claims Made and Reported" Policy

This is an application for a "claims made and reported" policy arranged with certain Underwriters at Lloyd's of London.

Completion of this document "ONLINE" is restricted to Australian and New Zealand RABQSA Certified Personnel who may also be legally authorized by the applicant to do so.

If a policy is issued, this application will attach to and become part of the policy. 

Please answer all questions. 

(1)
 Name of Applicant  or Firm
(2)
 Principal Business Address
 
 
Email address
 
(3)

Contact Person and

Phone Number
 
(4)
 Please identify your Competency-based certification: (please tick)
APIQ Auditor Bus Operator Accreditation Auditor
Coles Auditor Disability Services Auditor Drinking Water QMS Auditor
Environmental System Auditor Food Safety Auditor Heavy Vehicle Accreditation Auditor
Information Security Management Systems Auditor Japan Frozen Food Inspector Laboratory Assessor
Management System Certification Body Auditor National Food Safety Auditor Occupational Health And Safety Auditor
Quality Management System Auditor Security Management Systems Auditor Skill Examiner
 
 Please identify your Qualification-based certification: (please tick)
Aerospace As9120, As9003 Auditor Aerospace Auditor Other Aged Care Assessor
Environmental System Auditor Food Safety Auditor Haccp Practitioner
Internal Auditor Ipc Quality Management Systems Auditor Laboratory Assessor
Occupational Health And Safety Auditor Quality Management Consultant Quality Management System Auditor
Responsible Care Management Systems Auditor Cleaning/Disinfection Professional Valuers
 
(5)
 List the total gross receipts during the last full financial year for your professional services:
 
(6)
 What is the expiry date of your current policy?
 mm/dd/yyyy
 
(7)
 Have any claims or suits related to your professional services been made during the past five years against the Applicant, its predecessors in business, any of the past or present partners, directors, officers, or employees of the Applicant's business? 
 Yes No
  If yes, state briefly the date, nature and amount, the name of the claimant, and the current status or final disposition of the claim.
 
 
(8)
 Is the Applicant (after proper inquiry of each director, officer, partner or employee of the Applicant or any other proposed insured) aware of any circumstances, incidents, situations, or accidents in relation to your professional services which may result in claim being made against the Applicant, its predecessors in business or any of the present or past partners, officers, directors or employees?
 Yes No  
  If yes, give full details.
 
 

(9)

It is agreed that any claim or lawsuit against the Applicant or any other proposed insured arising from any facts, circumstances, acts, errors or omissions disclosed or required to be disclosed in response to question 6 and 7 above is hereby expressly excluded from coverage under the proposed insurance policy.

(10)

Stamp Duty is apportioned for each state in Australia commensurate with the income percentage declared. Whilst payment of the Stamp Duty is ultimately the responsibility of the insured party to a contract of insurance it is therefore prudent to ensure that the calculations below correctly reflect percentages declared.

Total must equal 100%

     

Notice To Applicant - Please Read Carefully

Warranty:

It is hereby Understood and Agreed, after proper inquiry of each director, officer, partner, or employee of the Applicant or any other proposed insured, that this application and its representations and warranties shall be deemed to be submitted by and on behalf of and be binding upon the Applicant and each and every proposed insured under the policy.   It is further agreed that any misrepresentation, non-disclosure, concealment, or breach of warranty in this application shall be binding upon the Applicant and each and every proposed insured under the policy whether or not the proposed insured knew of, committed, or was responsible for such misrepresentation, non-disclosure, concealment, or breach of warranty.

I/We hereby authorize the release of claim information from any prior insurer to the Insurer.

I/We understand and accept that the policy applied for provides coverage on a claims made and reported basis for only those Claims that are first made against the Applicant and reported in writing to the Insurer during the policy, that the limits of liability of the policy will include both Damages and Defense Expenses, and that the Insurer will rely upon the truth of the information and statements in this application in deciding whether to issue a policy to the Applicant.

The Applicant agrees that if the information supplied on or attached to this application changes between the time this application is executed and the time that the proposed insurance policy is bound or coverage commenced, the Applicant will immediately notify the Insurer in writing of such changes; and the Insurer fully reserves its rights with respect to the underwriting acceptance or denial of such changes.

I declare that as a current holder of RABQSA certification and as an Authorised Executive or Officer of the business/firm/trade, that I am Duly Authorised to complete this application which will be accepted by the insurer (or insurer's representative) as a true and correct record for the purposes of obtaining a non-binding quotation for the product (or products) to which the form applies

I agree  

 

"This application is provided by FirstCity Partnership Limited who are a broker at Lloyd's of London and who are regulated by the Financial Services Authority together with Envirosure authorized representative No: 269469, licensee a Division of Mackellar Insurance Brokers AFS Lic. No. 243531"

Address: PO Box 216 BALGOWLAH, NSW, 2093

Telephone: +61 (0)2 9949 1155

Fax: +61 (0)2 9948 4681

Email: envirosure@mackellar.com.au