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).
Please provide total number of current staff numbers (include any credit representatives and their staff)
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?
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
For each of the activities below, indicate the percentage of gross income / fees (noted in 6(a) above derived from:
Please note cover will NOT be provided in relation to a Delegated Lending Authority held by or on behalf of the Insured.
From the total activities noted in Question 7 above, please detail the % of loans for the last 12 months for the following loan types
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.
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)
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).
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.
Vendor management
Please identify the Insured Entity’s critical vendors:
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.
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.