PI+PL - !nsureAble

YOUR DETAILS

First Name:

Last Name:

Email:

Contact Number:

PERIOD OF INSURANCE REQUIRED

When would you like your insurance to start and end?
(Both at 4pm local standard time)

From:

To:

BROKER DETAILS (IF APPLICABLE)

Contact Name:

Contact Email:

GENERAL INFORMATION

Insured First Name:

Insured Last Name:

Business Name:

Insured Australian Business Number (ABN):

Occupation:

Is the Insured a registered Care Worker?

Yes No

Insured Address:

GENERAL QUESTIONS

Please advise which of the below activities are undertaken by the Insured:

Please list any additional activities not listed:

Please advise Insured's website:

Does the Insured Person perform any medical treatments or procedures that are required to be undertaken by a qualified medical practitioner?

Yes No

Does the insured offer respite or short-term accommodation outside of their clients house?

Yes No

Does the insured person dispense or prescribe prescription medication to their clients?

Yes No

DISCLOSURE INFORMATION

Have you ever had an insurer refuse or not invite renewal?

Yes No

Have you ever been declared bankrupt or put into receivership or liquidation?

Yes No

Have you ever been charged with or convicted of a criminal offence?

Yes No

Have you had any claims in the last 5 years for any of the insured risks?

Yes No

If you answered 'Yes' to any of the above, please provide full details:

Does the insured qualify for NSW Stamp Duty Exemption?

Yes No

COVER OPTIONS: General Liability

Limit of Liability Required:

$10,000,000 $20,000,000

Annual Turnover:

Does the Insured employ people?

Yes No

If Yes, please advise number of employees:

Does the Insured utilise Contractors/Subcontractors?

Yes No

If Yes, please advise total annual wages/payments to Contractors/Subcontractors:

Do all Contractors/Subcontractors hold their own insurance?

Yes No N/A

COVER OPTIONS: Professional Indemnity

Limit of Indemnity required:

$500,000 $1,000,000

Retroactive Date:

COVER OPTIONS: Individual Accident & Sickness

Scope of Cover:

Full name of Insured Person:

Date of Birth:

Weekly Accident Benefit:

Weekly Sickness Benefit:

Lump Sum Benefit:

Weekly Fixed Business Expenses:

Is the Insured Person covered by Workcover?

Yes No

Benefit Period:

52 Weeks 104 Weeks

Waiting Period:

7 Days 14 Days 21 Days 28 Days

Has the Insured Person had surgery or do they have any pre-existing medical conditions and if so do they receive treatment for this and/or take any medication?

Yes No

Does the Insured Person engage in any amateur or professional sporting activities?

Yes No

Will the amount of your weekly compensation from this policy and all other sources exceed your weekly salary or income?

Yes No

DECLARATION

By signing this application form You hereby declare that:

• You have received, read and understood the policy wording, in particular your duty of disclosure and what is excluded
• You agree to be bound by the terms and conditions
• The disclosed information is true and correct
• You have not withheld or suppressed any information concerning the details in this application
• If there is more than one insured and all have not signed this application, you are authorised to sign for and on their behalf.

You consent to the use and disclosure of your personal information for the purposes shown in the Privacy section of our Policy Wording and our Privacy Statement (available at XXXXXXXXXXX);

AND

You confirm that if you have disclosed personal information about any insured person or any other person you have made them or will make them aware that you have provided their personal information to us and the types of third parties we may provide it to, the relevant purposes we and third parties will use it for, and how the Insured Person or other person can access it.

I have read, understood, and agree to the above declaration.

By typing my name below, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

Date:

Ready to join us?

Public Liability + Professional Indemnity

YOUR DETAILS

PERIOD OF INSURANCE REQUIRED

BROKER DETAILS (IF APPLICABLE)

GENERAL INFORMATION

GENERAL QUESTIONS

DISCLOSURE INFORMATION

COVER OPTIONS: General Liability

COVER OPTIONS: Professional Indemnity

COVER OPTIONS: Individual Accident & Sickness

DECLARATION

Ready to join us?

Public Liability + Professional Indemnity

YOUR DETAILS

PERIOD OF INSURANCE REQUIRED

BROKER DETAILS (IF APPLICABLE)

GENERAL INFORMATION

GENERAL QUESTIONS

DISCLOSURE INFORMATION

COVER OPTIONS: General Liability

COVER OPTIONS: Professional Indemnity

COVER OPTIONS: Individual Accident & Sickness

DECLARATION

WE GOT IT!