Management Liability Form - IMC Insurance Brokers

Your Details

Name*

First Last

Contact Number*

Email*

Address*

Street Address Suburb State Postal Code

Details of Applicant

Insured Name*

Please list all entities to be insured under this Policy, including current subsidiary/incorporated joint venture companies

Web Address

Date Established*

Address of Head Office*

Street Address Suburb State Postal Code

Country State of Registration*

ABN/ACN*

Telephone Number*

Please select the company structure to be insured under this policy:*

Pty Ltd

Public Unlisted

Non profit/Association

Publicly Listed

Trust

Partnership

Sole Trader

Other

Please specify the type of Company structure*

Please describe the full business activities (including all subsidiary companies/controlled entities)*

History of the Company

Does the Company have any securities listed on any stock exchange such as the ASX or CXA?*

Please provide details*

Has the Company made or are there any pending acquisitions, mergers, divestments or material capital raisings in either the past or following twelve months?*

Please provide details*

During the last 3 years, has the Company changed its external auditors and/or legal advisors?*

Please provide details*

Is the Company involved in any business activities or does it hold any assets in the USA and/or Canada?*

Please provide details*

Does any shareholder own more than 50% of the Company’s Ordinary Share Capital?*

Please provide details*

Within the past 5 years has the Company or its Directors or Officers disclosed confidential information to any third party including potential business partners?*

Please provide details*

Has any employee that has had access to the Company’s confidential information left your employment within the past 3 years?*

Please provide details*

Financial Information

Please provide the Company’s Gross Consolidated Turnover in AUD$ (based on the average of last 2 years):*

Please provide the Company’s Gross Consolidated Total Assets in AUD$ (last actual financial year):*

Please provide the Company’s Gross Consolidated Net Assets in AUD$ (last actual financial year):*

In the past 3 years, has there been (or is there now proposed) any change in the financial position or capital structure that may materially affect the financial performance of the Company?*

Please provide details*

Is any Director or Officer of the Company aware of any facts or circumstances that may affect the ability of the Company to meet its debts as and when they fall due?*

The Policy contains an Insolvency Exclusion. On receipt and review of audited financial statements we can consider removing this exclusion.

Please provide details*

Do you have a current Management Liability Insurance Policy in place?*

Name of the Insurer*

Limit of Indemnity*

Deductible*

Expiry Date of the Policy Period*

Retroactive Date*

Please select the type of policy the company currently has*

Statutory Liability

Legal Expenses

Workers Compensation

Employers Liability

Tax Audit Expenses

None of the above

Name of the Insurer*

Limit of Indemnity*

Deductible*

Type of Policy*

Expiry Date of the Policy*

Retroactive Date*

Segregation of Operations

In respect of turnover for the last financial year, please provide a breakdown by State:

NSW %

ACT %

QLD %

VIC %

TAS %

SA %

WA %

NT %

O/S %

About the Employees

Segregation of Operations

Please provide the total number of your current employees:

Number of Board members, Directors, Partners & Officers

Number of full time employees excluding the above

Number of part-time employees

Number of casual employees

Number of independent contractors

Number of voluntary workers

Total number of employees*

Do you anticipate a significant change to the number of employees in the next 12 months?*

Is the Company or any of its subsidiaries undergoing any employee redundancies, layoffs, or early retirement (including those resulting from any type of company, restructure, acquisitions, divestment, office or plant closure) in the next 12 months?*

Please provide details*

Does the Company have written employment procedures (e.g. Employee Handbook) that are made available to each employee, and does the Company adhere to these procedures at all times?*

Please provide details*

Segregation of Operations

Based on your current year estimates, please fill in the number of employees in the following annual salary brackets:

$0 - $50,000

$50,000 - $100,000

$100,000 - $250,000

> $250,000

Are all of your employees engaged under a written contract of employment?*

Please provide details*

Segregation of Operations

Are decisions regarding redundancies, layoffs or negative performance evaluation always subject to prior review by the:

Company’s Human Resources or equivalent?*

Please provide details*

Internal Legal Department?*

Please provide details*

External Legal Counsel?*

Please provide details*

Employee Theft

Segregation of Operations

Do you ensure the following operations are always segregated so that no one person can control any function from start to finish without referral to another individual:

signing cheques or authorising payments above $1,000*

issuing funds transfer instructions*

amending funds transfer procedures*

opening new bank or supplier accounts*

refund of monies or return of goods above $1,000*

Do you always ensure bank statements are independently reconciled by persons not authorised to deposit/withdraw funds or to issue funds transfer instructions?*

Is an independent physical count of stock, raw materials, work in progress and finished goods undertaken and is this count reconciled against stock levels?*

How frequently?*

Were any discrepancies discovered during last stock check?*

Do you always ensure wages / salaries are independently checked against personnel records for unusual or excessive payments?*

Are passwords automatically withdrawn when staff members leave your employment?*

Do you maintain an approved suppliers list?

Segregation of Operations

Are suppliers, service providers and outsourcing companies:

vetted for competency, financial stability and honesty before being approved?*

Please provide details*

appointed under written contract?*

Please provide details*

Risk Management

Does the Company have a current manual for Occupational Health & Safety Procedures and Environmental Protection Procedures that is distributed to all workers?*

Please provide details*

Are all employees appropriately trained and inducted at the outset of their employment with the Company?*

Please provide details*

Does the Company have any workers that are engaged in any hazardous manual activities (including work in confined spaces, abrasive blasting, electrical work, diving and other high risk activities)?*

Please provide details*

Claims Details

After enquiry, is the proposed Insured aware of any facts or circumstances which might afford valid grounds for any future claim(s) or which would indicate the probability of any such claim(s) under any section of the cover for which it has applied?*

Please provide details*

Within the last three (3) years, has the proposed Insured been the subject of any complaint, suit, inquiry or notice of a hearing from any State, Territory or Federal regulatory body, or any other party?*

Please provide details*

Within the last three (3) years, has the proposed Insured discovered any losses from employee dishonesty, burglary, robbery, disappearances, destruction or forgery?*

Please provide details*

Has the proposed Insured been declined, had cancelled or non-renewed any insurance policies for any of the coverages for which it has applied?*

Please provide details*

Have any claims ever been made against the Company or any of its Directors, Officers or employees for wrongful termination, discrimination intimidation or sexual harassment?*

Please provide details*

In the past five (5) years has the proposed Insured had any fine or penalty imposed by, or been served an infringement, improvement or prohibition notice or enforcement order by Federal, State, Local Government or Regulatory Authority?*

Please provide details*

In the past five (5) years has the proposed Insured had a Workplace or Environmental incident (including a workplace fatality, serious injury or dangerous incident) that either required notification to, or warranted investigation by, a Regulatory Authority or a compulsory requirement to attend any hearing, inquiry, prosecution or other commission?*

Please provide details*

Has the Company ever had any Insurer decline a proposal or cancel or refuse Management Liability Insurance?*

Please provide details*

Indemnity Limit

Please select the amount of Indemnity required*

Please specify*

Please sign your name*

Name

Date