Business Insurance Application - Rooms, Day Surgery & Medical Centres

Business Insurance Application - Rooms, Day Surgery & Medical Centres

Everest Medical Indemnity is a registered trading entity of Everest Risk Group Pty Ltd and Corporate Authorised Representative (No 276869) of Insurance Advisernet Australia Pty Ltd (AFSL 240549)
General Advice Warning

The information provided is to be regarded as general advice. Whilst we may have collected risk information, your personal objectives, needs or financial situations were not taken into account when preparing this information. We recommend you consider the suitability of this general advice, in respect of your objectives, financial situation and needs before acting on it. You should obtain and consider the relevant product disclosure statement before making any decision to purchase this financial product

Your Privacy

We value your privacy. Our Privacy Policy sets out how we collect, disclose and handle personal information under the Privacy Act and the Australian Privacy Principals. By providing us such information you consent to these practices unless you tell us otherwise. Our Privacy policy is available at https://www.insuranceadviser.net/ia-privacy-policy or by contacting us.
GENERAL INFORMATION
Insured Name:*
(Legal name of Business or Entity to be insured):
ABN:
Australian Business Number
Your current insurance due date

DayMonthYear
Name of person responsible for insurance*

First NameLast Name
Phone Number *
E-mail:*

Confirmation Email(person responsible for insurance)
Risk Address: (where cover will apply)*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Occupation:*
Number of Employees *
(full time equivalent)
Practice revenue for the past financial year end*

	Enter Sum Insured
The Building sum insured required is (if strata titled or not owned by the Insured leave blank):
Total contents, fixtures, equipment, furniture & stock replacement value is
Burglary Sum Insured required is (leave blank if not required):
Money Sum Insured is (leave blank if not required):
Equipment Breakdown Sum Insured is (leave blank if not required):
Business Interruption Sum Insured is (leave blank if not required):

Duty of Disclosure

The Purpose of this application is to set out all relevant information for your adviser to submit on your behalf to the insurer(s). Under the Insurance Contracts Act 1984, you are under a duty to make full disclosure as follows:

Your Duty of Disclosure
Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contract 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 disclosure of matters –
 that diminish the risk to be undertaken by the insurer;
 that is of common knowledge;
 that your insurer knows, or in the ordinary course of their business, ought to know;
 as to which compliance with your duty is waived by the insurer.

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 opportunity of voiding the contract from its beginning. There are other matters of which you should be aware in relation to the proposed professional indemnity insurance, as follows:

Utmost Good Faith
A contract of insurance is based on the utmost good faith requiring the insurers and the insured to act towards each other with utmost good faith in respect of any matter arising in relation to the insurance.

Privacy
We are committed to protecting your privacy. To provide you with our services, which include negotiation and acquisition of insurance, we need to obtain certain information from you and pass it on to the third parties who are necessary to assist us in providing these services to you. These include insurers, accountants, lawyers and other advisers. We use the information you provide to advise about and assist with your insurance needs.

We do not trade, rent or sell your information.

For further information about our Privacy Policy, ask for a copy or visit our website www.everestrg.com.au

CLAIMS HISTORY & DUTY OF DISCLOSURE QUESTIONS:*

	Yes	No
In the past 3 years, has the Insured had more than 2 claims or claimable incidents, or had claims totaling more than $5,000 for the coverage being applied for?
In the last 5 years, has the Insured had any insurer decline a claim or proposal, cancel; or refuse to renew a policy, or impose special terms, conditions or restrictions on a policy?
In the last 5 years, has the Insured ever been placed in receivership or liquidation or been declared bankrupt?
In the last 10 years, has the Insured been convicted of a criminal offence

As you have selected "yes" to the above, please provide details:
Declaration

I/we declare and agree:

• that I/we have read and understood my Duty of Disclosure set out on this page of this application and understand that if I do not comply with this duty the Policy may be cancelled or a claim may be reduced or not paid (or both). If my non-disclosure is fraudulent my Policy may be voided from inception;

• that I/we have answered every question fully and frankly, have been truthful and accurate in completing this application and have not withheld any information likely to affect the acceptance of this insurance;

• to make the Premises available for inspection by the insurer if so requested;

• upon acceptance, this insurance shall be subject to the Business Pack Policy provided with the quotation;

• that I/we have the consent of all other persons covered by this Policy to provide personal and sensitive information on their behalf;

• If anything happens during the Period of Insurance which alters any of the information provided, I/we will promptly inform the Insurer.
Please acknowledge you have read and accept the above

I acknowledge the above Declaration
Name of Applicant

First NameLast Name
Position of Applicant
(e.g Director on behalf of the Insured)
Should be Empty:

	Yes	No	Not Applicable
Glass Cover
Portable Items whilst outside the Insured Risk Address
Management Liability (including Directors Liability, Employee & External Crime/Fraud, Fines/Penalties & Employment Practices Claims)
I have Workers Compensation in the each State and Territory where I employ staff?

	Yes	No
Re-plumbed
Rewired

Business Insurance Application - Rooms, Day Surgery & Medical Centres

RISK INFORMATION