Finance Brokers PI Plus Professional Indemnity Proposal Form

Finance Brokers PI Plus Professional Indemnity Proposal Form

Please read the “Statutory Notices” before completing this proposal form and if you donot understand any questions, please ask your adviser. The Finance Brokers PIPlus policy is written on a “Claims Made” basis. This means that claims, orpossible claims, must be notified before the policy expires or during anyapplicable Extended Reporting Period.
(1) Full Name of Company / Insured Entity:
(2) ABN:
(3) Current Member of any Industry Association:

Other
(4) Are you affiliated with an Aggregator Group?
Which Aggregator Group?

Other
(5) Business Establishment Date:
Example: 2011
If business established this year, please confirm your Experience AND Qualifications in the Finance Industry:
(6) Contact Person's Name:

First NameLast Name
Mobile Phone Number:
Format: (000) 000-0000.
Telephone Number:

Phone Number
(7) Email:
example@example.com
Street Address

Street / Postal Address

Address Line 2

CityState

Post Code
Postal Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

(8) Staff Numbers:

Rows
(a) Principals / Finance Brokers:
(b) Credit Representatives / Contracted Consultants:
(c) Administration Staff

(9) Do you wish to have contractors that operate as credit representatives under your licence covered by your policy?
(If Yes, please provide names and/or associated companies):

(10) Standard Business Activities Covered: Arranging loans and/or Mortgages and advice in relation to the terms and conditions thereof. Please provide split up of your business activities into the following categories:

Rows	Percentage (Must Total 100%)
Mortgage Broking / Origination
Loan / Mortgage Management (under contract on behalf of lender/s). Direct Lending Authority. If yes please provide copy of DLR Contracts:
Commercial Finance Broking
Motor Vehicle, Marine, Plant & Equipment Finance
Insurance Agent
Plant and Equipment Finance
Other (Please provide details):

(11) Do you have authority to approve or settle loans on behalf of credit providers / Lenders?
(If Yes, please provide FULL details including Delegated Loan Authority and copies of contract agreements for eachlender you have authority to approve or settle loans for and please advisewhich staff are authorised to approve or settle loans): :

(12) SOURCES OF CREDIT: Credit Provider

Rows	Percentage of overall loans: (Must Total 100%)
Banks, Credit Unions, Building Societies
Wholesale / Non-Conforming Lenders
* Private Equity / Investment / Superannuation Funds
* Off-shore Credit Providers
* Solicitors Funds
* Own Funds
*These Funders are NOT COVERED by the Policy unless Specifically agreed and endorsed thereon.

(13) In the last 12 months, of the total number of residential / investment property mortgages you arranged credit for, how many were in the following categories:

Rows	Percentage overall loan portfolio	Max Value Mortgage Provided
(a) Low Doc
(b) Deposit / Credit Impaired
(c) LVR greater than 90%

(14) Do you always conduct due diligence when verifying documentation submitted in loan applications by you or on your behalf for your clients?
(If No, please provide FULL details):
(15) Do you always ask the client to review and sign off the loan application before itis submitted to the lender?
(If No, please provide FULL details):
(16) Where you are required to witness a client's signature, do you always ensure this is done in your presence or witnessed by a Justice of the Peace?
(If No, please provide FULL details):
(17) Where you are required to provide 100 point ID check as part of the loan application contract process, do you always sight the original or JP verifieddocumentation?
(If No, please provide FULL details):

(18) Income, Fees, Commission (excluding GST):

Rows	$
Actual last 12 months:
Estimate for coming 12 months:

(19) Please provide breakdown of employee numbers by State:

Rows	NSW	QLD	ACT	VIC	TAS	SA	WA	NT	O/S
Percentage

(20) Please advise which level of cover is required: (note that each option has one automatic reinstatement of the limit):

Other
(21) Are you currently insured?
(If Yes, please provide FULL details):

(22) Do you require any of the following optional additional covers:

Rows	Yes	No
(a) Public & Products Liability
(b) Management Liability - (Directors and Officers Liability, Employment Practices Liability etc)
(c) Cyber Risk - (Cyberattack, loss of data & associated retrieval costs, ransom demands, incident response assistance, damage to hardware, business interruption / downtime losses & optional Funds Transfer Fraud & Telephone hacking [subject to approval]). To arrange a Cyber Quotation, please complete online form: Finance Broker Cyber Proposal Form (jotform.com)
(d) Office Package - (Property/ Contents / Theft / Glass &/or Mobile Electronic Equipment) To arrangeOffice Pack quote, please complete online form: https://form.jotform.com/IABroadbeach/office-pack-prop

(23) Prior Knowledge / Warranty:

Rows	Yes	No
Has the Applicant or any person proposed for coverage given notice under the provisions of any prior or current Professional Liability Insurance, Fidelity Bond, Directors or Officers Liability or Employment Practices Liability or similar insurance of facts or circumstances which might give rise to a claim being made against any such person?
Have any loss payments been made on behalf of any Applicant or any person proposed for coverage under any Professional Liability, Fidelity Bond, Directors or Officers Liability or Employment Practices Liability or similar Insurance?
Is the company or Principal or Credit Representative(s) aware of any circumstance(s) which may result in a claim being made against the Company, or against any Principal or Credit Representative(s), or against any partnership or company of which any Principal or Credit Representative(s) is/was a partner, director, CEO or Credit Representative?
Has any person or entity seeking cover under this policy ever been subject to disciplinary proceedings for professional misconduct and/or been investigated by any regulatory body or association and/or been banned and/or disqualified?
Has any person or entity seeking cover under this policy ever been declared bankrupt?

If ‘Yes’ to any of the above, please provide FULL details:
Name of applicant:

First NameLast Name
Digital Signature
Should be Empty: