Step 1 - Mortgage Broker Professional Indemnity Application Form

Scott & Broad Pty Ltd act on behalf of Insurance Australia Limited trading as CGU Insurance when dealing in this financial product.

Please complete the Mortgage Insurance Application below. Our policy coverage complies with all the MFAA/FBAA Insurance requirements. If you have any questions when you are completing the form please call William Gomez on (02) 9932 6425

* Indicates a mandatory field.
1. Proposed date of inception of insurance
 * Please enter the date or estimated date of when you would like cover to begin:
Please note
  • the inception date of any policy commences at 4:00pm EST on the date the policy begins
  • the inception date cannot be a date either prior to or more than 6 weeks after the current date
2. Details of Proposer
Important Note:
Please note if the below proposed Insured is a Credit Licensee, cover will only extend to its Credit Representatives (whether incorporated or not):

(i) where the Total Gross Income /Fees of such Credit Representatives have been included in response to question 6 of this Proposal Form (Total Gross Income / Fees); and
(ii) where such Credit Representatives have been individually nominated to be covered in response to question 4 of this Proposal Form (Credit Licensee / Credit Representatives); and
(iii) in relation to the Professional Services performed for and on behalf of the below proposed Insured (subject to policy terms and conditions).
b) Do you hold or are you authorised to perform credit services under an Australian Credit Licence? (i.e. either your own ACL or aggregators ACL)
Yes  No
h) Postal Address
Is your street address different to your postal address?
Yes  No
3. Current Staff Numbers
Please provide total number of current staff numbers (include any credit representatives and their staff)
4. Credit Licensee, Credit Representatives
Important Note: In response to the below request please:
  • only name Principals (which includes a natural person who is a sole trader, director or partner) of the legal entity noted under Question 2(a) above; and
  • only name Credit Representatives to be covered by this insurance who perform Professional Services for and on behalf of the legal entity noted under Question 2(a) above.
  • do not include employees if either of the above
  • note, cover will not extend to any Credit Representative where the Total Gross Income /Fees of such Credit Representatives has not been included in response to question 6 of this Proposal Form (Total Gross Income / Fees)
5. Risk Management Questions
Are you a full member of any Professional Associations?
Yes  No
Of your Credit Licensees/Credit Representatives to be insured by this insurance, have at least 50% either enrolled or completed one of the following Diploma courses?
Diploma or upgrade Diploma in Financial Services (Finance/Mortgage Broking Management) FNS50504 or the Diploma of Finance and Mortgage Broking Management FNS50311 / FNS50310
Yes  No
I / We declare that any entity or natural person to be insured by this insurance always carries out and documents an assessment with the client of their borrowing capacity
Yes  No
I / We declare that any entity or natural person to be insured by this insurance always verifies the income of the borrower
Yes  No
I/We declare that any entity or natural person to be insured by this insurance always sights original documents and undertakes 100 point ID Checks for all borrowers (including any guarantor) where this is a requirement of the Lender
Yes  No
I / We declare that any entity or natural person to be insured by this insurance always maintains records of all verbal agreements / instructions
Yes  No
I / We declare that any entity or natural person to be insured by this insurance always documents discussions with the client and the impact that interest rate increases will have on repayment
Yes  No
I / We declare that the any entity or natural person to be insured by this insurance has not been expelled or suspended
Yes  No
6. Total Gross Income / Fees
Please provide the total amount of the proposed Insured's gross income and fees (not the value of loans processed) for the following periods:
Important Note: If the proposed Insured is a Credit Licensee, gross income and fees must include gross income and fees earned by any Credit Representatives of the proposed Insured to be covered by this insurance
(a) Last 12 months (if you have been trading less than 12 months please provide 12 month estimate from the start of the business)
(b) Are you an Aggregator?
Yes  No
7. Breakdown of professional services
For each of the activities below, indicate the percentage of gross income / fees (noted in 6(a) above derived from:
b) Mortgage Administrator (no delegated lending authority)
Please note cover will NOT be provided in relation to a Delegated Lending Authority held by or on behalf of the Insured.
8. Loan Size
9. Loan Types
From the total activities noted in Question 7 above, please detail the % of loans for the last 12 months for the following loan types
a) Residential (not including reverse mortgages, non-confirming, low doc loans or vendor finance)
b) Commercial / Car Finance / Industrial / Leasing Equipment (not including non-conforming, low doc loans, or vendor finance)
c) Reverse Mortgage, Non-conforming, “Low Doc” loans (not including Vendor Finance)
d) Vendor Finance:
100% 
10. Claims Declaration

Please enquire within your organisation to ensure that all known claims and/or circumstances likely to become a claim, are identified and reported to your insurer prior to your current expiry date.

Failure to do so may result in cover being denied for such incidents as this is a CLAIMS MADE policy.
a) After enquiry of the Partners/Principals/Directors/employees or Credit Representatives, has there been or is there now pending a claim against any entity to be insured by this insurance, it’s predecessors in business or its current or former Partners/Principals/Directors/employees or Credit Representatives for a breach of professional duty?
Yes  No
b) After enquiry of the Partners/Principals/Directors/employees or Credit Representatives, is the entity to be insured by this Insurance aware of any circumstance or incident which may give rise to a claim against such entity or any of its Partners/Principals/Directors/employees or Credit Representatives ?
Yes  No
c) After enquiry of the Partners/Principals/Directors/employees or Credit Representatives, is the entity to be insured by this Insurance aware of any prosecution or investigation (actual or pending) of the entity to be insured by this insurance or any of its Partners/Principals/Directors/employees or Credit Representatives under any international, commonwealth, state or local statute, legislation or by law ?
Yes  No
d) After inquiry of the Partners/Principals/Directors/employees or Credit Representatives, has the entity to be insured by this Insurance or any of its Partners/Principals/Directors/employees or Credit Representatives ever been subject to any disciplinary action, been fined or penalised, or been the subject of any inquiry investigating or alleging professional misconduct?
Yes  No
11. Professional Indemnity Insurance
a) Does the proposed Insured currently have a Professional Indemnity policy in force?
Yes  No
b) Has the proposed Insured ever had any insurer decline a proposal, imposed any special terms, cancelled or refused to renew a Professional Indemnity Insurance Policy?
Yes  No

Please note to comply with new legislation your minimum Policy limit should be $2,000,000 anyone claim and $6,000,000 in the Aggregate.


12. Stamp Duty
For the purpose of calculating Stamp Duty , please state the % loans processed for each state in the last 12 months (or 100% in your state of domicile if a new broker)
NSW:
VIC:
QLD:
SA:
WA:
TAS:
ACT:
NT:
13. Public Liability Insurance
This Broadform Liability policy includes public/products/advertising liability insurance (this is a separate policy)
Important Note: The Policy Limit under the Broadform Liability Insurance is $20,000,000 any one occurrence (for public liability) and in the aggregate (for products liability and advertising liability).
a) Do you require Broadform Liability Insurance (which includes Public/Products/Advertising Liability Insurance)?
Yes  No
14. Cyber Cover Extension
This extension provides cover for privacy breach claims, system damage losses, computer virus transmission and hacking claims, multimedia claims, cyber extortion costs, privacy fines & investigations and rewards expenses cover (cover subject to the terms and conditions of the Cyber Cover Extension). Important Note: This is an Extension to the professional indemnity policy. The total aggregate Specific Cover Limit under this Extension is $250,000, which amount is inclusive of the Policy Limit under the Professional Indemnity policy.
Do you require the Cyber Cover Extension?
Yes  No
Declaration & Important Information
I confirm I have read the important information below ?
Yes  No
I/We hereby declare that: My/Our attention has been drawn to the Important Notice accompanying this Proposal form and further I/we have read these notices carefully and acknowledge my/our understanding of their content by my/our signature/s below. The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this Proposal form and the inception date of the insurance to which this Proposal relates I/we shall give immediately notice thereof. I/We authorize CGU Professional Risks, Insurance Australia Limited trading as CGU Insurance, to collect or disclose any personal information relating to this insurance to/from any other insurers or insurance reference service. Where I/we have provided information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact and the section in the Policy on “The way we handle your personal information”.I/We also confirm that the undersigned is/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this Proposal form and I/we complete this Proposal form on their behalf. To be signed by the Chairman/President/Managing Partner/Managing Director/Principal of the association/partnership/company/practice/business.

Please read and retain in your file. IMPORTANT_NOTICE_TO_APPLICANTS.pdf

Once you have answered all the questions above, please click on the submit button below and the Proposal will be saved.

If your Proposal contains errors, you will be taken to the beginning of the form where the fields will be highlighted in red.


* Indicates a mandatory field.