Initials _____________ Page 1 of 7 INSURANCE REVIEW Austbrokers Coast to Coast as your Insurance Broker have an obligation to advise you on Insurance risks that are relevant to you and which may currently be uninsured, based on the information which you have provided to us. Find set out hereunder, a list of Insurances that are available and should be reviewed in conjunction with your existing covers (if any). This list is not an exhaustive list of all types of insurance covers available and could vary from time to time depending on your business needs. We appreciate not all classes of insurances will be relevant to you or your business. However, as business is continually changing, we recommend that you review your insured risks regularly to ensure that you remain comfortable with your existing range of policies. Tick the Yes box and return to us / contact us for placement of an uninsured exposure, if required. Confidentiality This document contains information which is confidential to you\your business and Austbrokers Coast to Coast Pty Ltd Accordingly, we trust you will understand this document is provided to you\your business and its officers, employees and representatives in confidence and may not be reproduced in any form or communicated to any other person, firm or company without the prior approval of Austbrokers Coast to Coast Pty Ltd. Client Profile Insured name(s): Client Code: Street Address: Group Code: ABN: Annual Renewal Date: Postal Address: Business Ph: Private Ph: Email: Mobile Ph: Website Yes I would like to receive your marketing material, any of my personal policy information and general communication with your office by email I would only like to receive policy information and general communication with your office by email If you do not want to receive any email communication from our office please do not supply your email address as this will be updated on your file Is there anything else we need to update?
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Initials _____________ Page 1 of 7
INSURANCE REVIEW Austbrokers Coast to Coast as your Insurance Broker have an obligation to advise you on Insurance risks that are relevant to you and which may currently be uninsured, based on the information which you have provided to us. Find set out hereunder, a list of Insurances that are available and should be reviewed in conjunction with your existing covers (if any). This list is not an exhaustive list of all types of insurance covers available and could vary from time to time depending on your business needs. We appreciate not all classes of insurances will be relevant to you or your business. However, as business is continually changing, we recommend that you review your insured risks regularly to ensure that you remain comfortable with your existing range of policies. Tick the Yes box and return to us / contact us for placement of an uninsured exposure, if required.
Confidentiality This document contains information which is confidential to you\your business and Austbrokers Coast to Coast Pty Ltd Accordingly, we trust you will understand this document is provided to you\your business and its officers, employees and representatives in confidence and may not be reproduced in any form or communicated to any other person, firm or company without the prior approval of Austbrokers Coast to Coast Pty Ltd.
Client Profile
Insured name(s): Client Code:
Street Address:
Group Code:
ABN:
Annual Renewal Date:
Postal Address:
Business Ph:
Private Ph:
Email: Mobile Ph:
Website
Yes I would like to receive your marketing material, any of my personal policy information and general communication
with your office by email
I would only like to receive policy information and general communication with your office by email
If you do not want to receive any email communication from our office please do not supply your email address as this will be updated on your file
Is there anything else we need to update?
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Authorized Contact(s) on Account
Name Salutation Position Phone Email DOB
Additional Information
Insured Name Changes
Business Description Changes
Turnover $
NSW VIC SA WA QLD TAS NT ACT O/S
Number of Staff
NSW VIC SA WA QLD TAS NT ACT O/S
Additional Details
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Asset Risks & Exposures
Exposure Brief description Insured Not
Required Please Quote
Fire and Perils Damage to fixed assets caused by a range of nominated risks.
Do you wish to insure for flood cover (Inundation by water from any watercourse, lake, canal, dam or reservoir)
Yes No
Does your building contain any Expanded polystyrene (EPS)? Yes No
Does your building contain any asbestos\fibro? Yes No
Please provide further details if answered yes:
If insuring building(s): It is important to review your building sums insured to ensure it is adequate. If you wish to calculate and approximate guide, please see the Insurance Council website www.understandinsurance.com.au/calculator/building-calculator
General Property
Loss and/or damage contents/stock whilst away from the insured premises.
Burglary Theft of property following break and enter.
Money Loss or damage to cash, cheques and negotiable instruments.
Fidelity Common Fidelity Insurance claims are a result of employee dishonesty, embezzlement, forgery, robbery, safe burglary, computer fraud, wire transfer fraud, counterfeiting, and other criminal acts.
Glass Damage to fixed glass and signs.
Business interruption
Loss of trading income and increased expenses due to damage to fixed assets.
Machinery & Electronic Equipment
Mechanical and Electrical breakdown of equipment
Tax Audit Expenses due to unexpected tax audit (including GST).
Contract Works
Loss or damage to the project during construction.
Corporate Travel
Costs following accident or illness whilst travelling.
Trade Credit Insurance
This provides protection for insured debts following insolvency of a debtor
Workers’ Compensation
Providing cover for employers’ liability for injury to employees, Act benefits and at Common Law.
Commercial Vehicle(s) Risk Exposures
Exposure Brief description Insured Not
Required Quote
Motor Loss or damage to registered vehicles.
We recommend annual declarations should be completed for all drivers of your vehicles. Please see your broker for a copy of this declaration.
Motor – CTP Bodily injury arising from registered vehicles (separate insurance not applicable in Western Australia)
Contractors' Plant & Machinery
Loss or damage to unregistered mobile plant/machinery, drilling rigs and the like.
Road Side Assist Available for Allianz commercial and domestic policies only up to 3.5T
Public Liability Bodily injury/property damage arising out of the insured’s business activities.
Products Liability Bodily injury/property damage arising from products manufactured, imported or sold.
Property Owners Liability Bodily injury/property damage arising from the ownership of property.
Contractual Liability Do you require the policy to be extended to provide cover for claims under an indemnity and/or hold harmless term of a client contract?
Imports/Exports Do you Import and/or Export?
Product Tamper/Recall Expenses incurred in the recall of defective products.
Environmental Impairment Liability
Bodily injury and property damage following gradual pollution. Clean up or remediation costs and expenses
Professional Indemnity Risks and exposures
Exposure Brief description Insured Not
Required Please Quote
Professional Indemnity or Errors and Omissions
A professional indemnity policy protects you for negligent acts and omissions that may harm your clients and others that may have relied on your advice. Do you provide advice for a fee? Are you required to have this cover under any contract?
Contractual Liability Would you like the policy to be extended to provide cover for claims under an indemnity and/or hold harmless term of a client contract (to the extent that such civil liability results from your performance of professional services)?
Fidelity Would you like the policy to be extended to provide cover for losses suffered due to the fraud or dishonesty of an employee?
Statutory Liability Would you like the policy to be extended to provide cover for penalties imposed for contraventions of statutory civil penalty provisions and no fault criminal offences (arising from your performance of professional services)?
Design & Construct insurance
Provides financial protection for businesses (including contractors) in the construction industry against financial losses arising from liability, including liability assumed from subcontractors.
Information and Communication Technology
Insurance policy is designed to protect information technology professionals and businesses.
Aviation Risks & Exposures
Exposure Brief description Insured Not
Required Please Quote
Aviation Liability Bodily injury and property damage arising from the operation of an aircraft.
Aviation Hull Loss of or damage to aircraft and related equipment.
Airport Operators/Airfield Bodily injury and property damage arising from the operation of a licensed airport.
Airside Operation Is your business and/or vehicle/s exposed to airside activities?
Drones / Remotely Piloted Aircraft Systems (RPAS)
Loss of or damage to drone and related equipment
Drone Liability Bodily injury and property damage arising from the operation of drone
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Management Liability Risks & Exposures Management Liability consists of many different sections. They are specifically designed to assist businesses of all sizes survive the complex threats of litigation and crime that may expose their bottom line. Management Liability policy covers the company/legal entity, directors and officers against claims resulting from management decisions. A brief overview of the cover is stated below.
Employment Practices Insurance - protects the company, its directors, officers and employees from claims brought by current, past or prospective employees. e.g. wrongful dismissal, incorrect payment issues, failure to protect (bullying) etc. – employees and subcontractors
Statutory Liability – breaches of government acts with potential for fines/ litigation / legal inquiries – pays fine and legal costs
Tax audit - proceedings from the government (director only covered for this if it relates to a company audit)
Directors' & Officers' Liability Insurance - protects the directors and officers against claims resulting from management decisions.
Employee Theft Insurance - protects the company from direct losses resulting from employee theft.
Internet Liability Insurance - protects the company against traditional publishing related exposures created by the existence of a company website.
Trustees Liability Insurance - protects the company, management and employees involved in the management of the Superannuation Fund and the Funds themselves against losses.
Kidnap Ransom and Extortion - The Company shall reimburse the Principal Organisation for direct loss of property or other consideration surrendered as payment by or on behalf of an Principal Organisation resulting from Kidnapping, Extortion Threat or Cyber Extortion.
Exposure Brief description Insured Not
Required Please Quote
Management Liability As per above
Cyber Risk Exposures What does Cyber Liability Insurance cover? Data Recovery Expenses - Expenses for an organisation to repair and restore their computer systems, including third party forensic IT experts. Privacy Notification & Crisis Management Expenses - Expenses for an organisation to notify individuals and regulators of a data breach,
including legal, forensic and public relations costs. Business Interruption Expenses - Loss of income for an organisation due to a cyber-event occurring at their business. Data Extortion Expenses - Expenses to deal with a cyber-extortion threat and reward payments Security & Privacy Liability - Coverage for claims from third parties in relation to multimedia content, including libel/slander and defamation
issues. Cyber Incident Response Hotline 24/7 An immediate response to a cyber-threat or data breach is required. With a dedicated 24/7 incident hotline number and you have access to an emergency response team to manage incidents from the moment they occur, no matter what time of day or night.
Marine Builders Risk Loss of damage to vessels during construction, testing and commissioning and delivery.
Marine Cargo Damage to goods while in transit.
Marine Hull Damage to private and commercial vessels and related equipment.
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People Exposures and Protection As we are not authorized to advise you about or arrange life insurance on your behalf, this part of the Checklist is provided for information purposes only. If you would like advice about your life insurance needs, we recommend that you contact:
Exposure Brief description
Group Life Cover Provides a group of people with cover for death or disability at much lower rates than can be provided individually.
Journey Cover Injury to employees solely and directly occurring whilst in direct travel to and from work.
Key Man Financial loss following death or disablement of key personnel.
Major Trauma Cover Provides lump sum of money following diagnosis of specified major personal health conditions.
Partnership and Shareholder Protection
Provides a package designed to protect the surviving shareholders in the event of the death or disability of a principal.
Personal Accident & Illness Death or disability following an accident or illness (Cancellable contract).
Income Protection
Provides cover in the event a person is unable to follow their chosen occupation. (a non-cancellable contract).
Salary Continuance This provides cover for continuation of employees’ salaries after sick leave has been exhausted.
Domestic Risk Exposures
Exposure Brief description Insured Not
Required Please Quote
Home and Contents
Loss or Damage to your personal home and\or contents, holiday homes and\or apartments
Landlords Cover Loss or Damage to your rental properties, loss of rent and cover for rent default
Residential Body Corporate Loss or Damage to your Residential Strata Buildings
Personal Motor Vehicles Loss or Damage to your personal motor vehicles for comprehensive, third party, fire and theft or third party only
Caravan or Motorhome Loss or Damage to your personal caravan or motor home
Pleasure Craft Loss or Damage to your personal pleasure craft
Personal Travel Costs following accident or illness whilst travelling. Please visit our website to obtain a quote and/or cover www.abc2c.com.au
Referral We take pride in servicing our clients and have a large emphasis on maintaining and building long standing relationships. We believe one way of doing this is helping the people around our clients through way of referral. Would you be able to assist us in providing details of another business owner, friend or relative that would benefit from our service?
Contact Name:
Business Name:
Contact Number:
Contact Email Address:
To assist with the referral, we kindly ask for you to contact them first so they will be expecting our call.
SolutionsAustbrokers Financial
244252 - Phone: 07 3434 7820 or contact our office for a referralAuthorised Representative of Millennium3 Financial Services Pty Ltd | ABN 61 094 529 987 | AFSL No: ABFS (QLD) Pty Ltd | ABN 90 107 534 501 | Corporate Authorised Representative No 270871 | is a Corporate
Methods of Payment Please see below the various methods of payment. Can you please confirm which method of payment you would like to proceed with for renewal so we can arrange this with you?
Cheque Made payable to Austbrokers Coast to Coast Pty Ltd Bpay Details will be provided on renewal invoice Visa or Master Card Details will be provided on renewal invoice. www.abc2c.com.au\payment OR Ph 07 5586 9955 Premium Funding Details will be provided on renewal invoice
Signature & Duty of Disclosure Before you enter into a contract of general insurance with an Insurer, you have the duty, under the Insurance Contracts Act 1984 to disclose to the Insurer every matter that you know or could reasonably be expected to know, is relevant to the Insurer’s decision whether to accept the risk of the insurance and if so, on what terms. You have the same duty to disclose those matters to the Insurer before you renew, extend, vary or reinstate a contract of general insurance. Your duty, however, does not require disclosures of matter: 1. that diminish the risk undertaken by the Insurer; 2. that is common knowledge; 3. that your Insurer knows, or in the ordinary course of his business, ought to know; and 4. as to which compliance with your duty is waived by the Insurer.
Consequence of Non-Disclosure If you fail to comply with your duty of disclosure, the Insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the Insurer may also have the option of voiding the contract from its beginning.
Claims Experience YES NO
Do you have any incurred but not reported claims? Are you aware of any instances which could give rise to a claim? If yes to any of the above please provide further details:
By signing I agree that I have reviewed all covers on the attached list and do not require any additional insurance other than what I have ticked. This is based on the needs of my business including any legal or statutory obligations and\or requirements. I confirm that the information I have provided is true to the best of my knowledge at this given time and that I am an authorised representative of this insured company\person.
Full name of Authorised Person
Signature
Date
If yes to any of the above please provide further details:
Are there any other matters you should disclose?
Have you been convicted of any criminal offence?
Have you had any claim rejected been declared bankrupt, or put into receivership or voluntary liquidation?
Have you had special policy conditions imposed?
Have you previously been declined cover, have cover cancelled or not renewed by an insurer?
insurance is now requested?
Have you ever sustained any loss or damage or incurred any liability, whether or not insured, of a type against which
