Management Liability Proposal

Name of Applicant(s) Requesting Insurance:

Please note: the entity must be “Pty Ltd”, “Limited by Guarantee” or “Incorporated” to qualify for Management Liability. Note: It is agreed that whenever used in this proposal form, the term 'Applicant' shall mean the Organisation and all its Subsidiaries

Year Established:

Applicants Principal Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Your Name:

First NameLast Name

Your Email Address:

Confirmation Email

Phone Number

Area CodePhone Number

Company Website:

Commencement Date of Insurance:

DayMonthYear

Occupation:

Australian Business Number (ABN):

Please select the classes to be insured from the following list:

Please provide the following information:

Rows	This Year	Last Year
Revenue
Number of Employees
Number of Locations

Are any of these locations based outside of Australia?

As you have selected yes, please list the locations:

Has any proposed Applicant been declined, had cancelled or non-renewed any insurance policies for any of the coverages for which they are applying?

As you have selected yes, please provide details below:

Has any Applicant proposed suffered any loss, whether covered by insurance or not, that would have fallen within the scope of the proposed coverage?

As you have selected yes, please provide details below:

Details should include Date of Loss/Amount of Loss/Details of Loss & the current claims status

Is any Applicant aware of any facts, circumstances, acts or omissions that may give rise to any future claims that would fall within the scope of the proposed coverage?

As you have selected yes, please provide details below:

Does the Applicant hold an Australian Financial Services License?

As you have selected yes, please describe the financial services offered:

Please provide the following information from your financials:

Rows	This Year	Last Year
Total Assets
Net Assets
After Tax Profit/Loss

Does the Applicant wish to remove the Financial Impairment Exclusion? If Yes, to consider removing please attach the Applicant’s audited or externally prepared Financial Statements for the past two (2) years

Are there any facts or circumstances that might affect the ability of the Applicant to meet all its debts as and when they fall due?

As you have selected yes, please explain in detail:

Does the Applicant generate revenue, have assets and/or employees based in North America?

As you have selected yes, please provide the following:

Rows	This Year	Last Year
a) total gross assets in North America
b) total revenue generated in North America
c) total number of employees in North America
d) total number of employees in the States of California and West Virginia

Does any person or entity own more than 25% of the issued share capital of the Company?

Over the last twelve months has the Applicant undergone any merger and/or acquisition activity or change in ownership >50% of the issued share capital of the Company?

Work Health & Safety

Rows	Yes	No
Does the Applicant have a safety management system in place?
Does the Applicant have a safety management system that complies with AS/NZ 4801?
Does the Applicant have effective hazard and incident reporting procedures?
Does the Applicant have procedures in place to identify and notify officers on duty under WHS laws?
Does the Applicant have a system that recognize contractors, volunteers, work experience students and labourhire employees as workers?
Does the Applicant have an audit program of its safety management system to ensure it remains effective and up to date in managing health and safety risks in the workplace?

Is there any further information relevant to your OH&S/WHS obligations

As you have selected yes, please explain in detail:

What percentage of employees are based overseas (including full time, part time and casual)

Please enter a whole number

How many directors and/or employees left the Applicant in the last six (6) months?

Please enter a whole number

How many retrenchments or layoffs does the Applicant expect to incur within the next twelve (12) months?

Please enter a whole number

Does the Applicant have written employment procedures (eg Employee Handbook) that are available to each employee?

Crime Cover Questions

Rows	Yes	No
Does the Applicant maintain a master list of authorised suppliers?
Are dual authorities required for all fund transfers, including deposits, transfers and withdrawals of the Applicant’s funds?
Are countersignatures required on all cheques?
Can the person who reconciles the monthly statements also handle deposits?
Is an independent physical count of stock, raw materials, work in progress and finished goods undertaken and is this count reconciled against stock levels on a quarterly basis?
Is the inventory check reconciled against inventory records by a person who is not the sole person performing the inventory check?

Social Engineering Fraud means the intentional misleading of an Employee*, through misrepresentation of a material fact which is relied upon by an Employee*, believing it be genuine.

Rows	Yes	No
Does a Social Engineering Fraud risk management strategy exist and has the Applicant informed and alerted relevant staff at all locations of Social Engineering Fraud?
Does the Applicant's email server and/or internet service provider (ISP) use any authentication methods at all locations?
Does the Applicant use a third party software product to enhance email authentication procedures at all locations?
Does the Applicant verify new customer or supplier bank account information (including name, address and bank account number) prior to initiating any financial transaction with such supplier or customer?
Does the Applicant have callback procedures with customers or suppliers to authenticate any fund transfer instructions greater than $50,000 prior to transfer?
Does the Applicant upon receipt of any email requests to change supplier or customer bank account details (including account number, email address, contact information, bank routing number) Have direct callback procedures in place (i.e. other than responding via email) to the contact phone number in place prior to receipt of the change request?
Does the Applicant upon receipt of any email requests to change supplier or customer bank account details (including account number, email address, contact information, bank routing number) Require internal dual signoff from a supervisor or authorised person prior to initiating the change request?

Please comment on any other controls you may apply:

Please state the total number of employees located in the following states and overseas:

Rows	Number
NSW
VIC
ACT
QLD
SA
WA
TAS
NT
O/S

Signature

Name

First NameLast Name

Title

Date

DayMonthYear