GSA

PLEASE ANSWER QUESTIONS FULLY, USE BLOCK LETTERS AND TICK APPROPRIATE BOXES

Name of Proposer and ABN (include all subsidiary companies, trading names & trustees for whom cover is required)*

Telephone Number * Fax Number *

Email Address *

Website Address *

Address of Principal Office *

Suburb* State* Postcode*

Total Number of Principals and Staff *

Date Proposer commenced business operations * dd/mm/yyyy

Please state the fee income derived from each of the following services within Australia and NZ: *

	Training Services	Past 12 months	Next 12 months
A	Accredited Training	$	$
B	sumNon Accredited Training	$	$
C	Other Professional Services	$	$
	TOTAL	$	$

Please provide a detailed description of the type of training provided: *

Accredited Training:

NON Accredited Training:

Other Professional Services:

Do you require cover for Other Professional Services from above?: Yes NO

BREAKDOWN OF TRAINING SERVICES

Please detail the approximate percentage of the Proposer’s fee income derived from the following classes of training:

CLASS	TYPE OF TRAINING	EXAMPLE	PERCENTAGE
CLASS A	Class Room & on-line / distance education training – which does not include a physical component.	Trainer provides training in a traditional classroom environment i.e. one in which uses a black board, white board, power point presentations, overhead projector training, reading or language teaching, computer training. Etc
CLASS B	Class Room training where a minor physical component within the training is provided.	Trainer provides training in arts and crafts such as painting, calligraphy, knitting, origami, music teachers, sculpture, pottery, card marking) etc. Any use of machinery should not be classed in this category. Etc
CLASS C	Indoor Training where the training provided includes a physical component	Yoga, dance instructors, woodwork, tai chi, fitness instructor, hairdressing. Etc
CLASS D	Outdoor Training Includes any minor to severe physical training.	Driver training, snorkeling, martial arts instructors, weapons instructors, operation of machinery and or equipment. Etc
TOTAL			100%

a) For any Class C or D training, please detail the type of training and the environment in which training is provided.

b) Please also outline any safety precautions which have been implemented to minimise the risk of injury being sustained to persons.

Do you require cover for students who are placed in the workforce to gain practical work experience as a pre-requisite to obtaining their qualifications/certificate? * Yes NO

If yes, please advise what professional services are being performed by students on placement.

Important Note:

Note where we provide cover for these services, insurance is restricted to services performed whilst under the supervision of a qualified employee of the host company (where these services are offered and arranged by you). Additional premium may be applicable in these circumstances.

10.

Please provide a breakdown of percentages in fee income by location as follows

NSW	VIC	QLD	SA	WA	TAS	ACT	NT	O/S
%	%	%	%	%	%	%	%	%

If the insured has any fee income from overseas please complete the following:

Country	Fee’s	Number of Staff	Services
	$
	$
	$

11.

Do you have an NTIS Registration in respect of the Accredited Training course you provide? Yes NO

12.

Is the Proposer a member of a professional association? Yes NO

If “Yes”, please provide details:

13.

Does the Proposer have other Professional Indemnity Policy in force Yes NO

If “Yes”, please provide the following details:

Name of Insurer Renewal Date

14.

State the Limit of Indemnity required under this insurance:

$1,000,000 $2,000,000 $5,000,000 Other $

PUBLIC AND PRODUCTS LIABILITY

15.

Public and Products Liability – Optional Separate Policy

Important Note:

Please note that this optional extension for public and products liability is offered on an “occurrence basis”. This means that the Policy responds to Claims that occur during the policy period.

a) Do you require a quote for public and products liability? Yes No

If Yes, please answer the following: Indicate the Limit of Indemnity required

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

b) Do you engage contractors/sub-contractors? Yes NO

b) If Yes, - Please provide details of their activities and estimated annual payments:

CLAIMS AND CIRCUMSTANCE DETAILS

16.

a) Has any claim been made against the Proposer or any principal, partner, director, consultant or employee in respect of the risks to which this proposal relates?

Professional Indemnity Yes NO Public and Products Liability Yes NO

b) Has the Proposer or any principal/partner/director/ consultant or employee incurred any other loss or expense which might be within the terms of cover? Yes No

If yes in either case, please attach separate sheet providing full details including what action has been taken to prevent a recurrence of the situation which gave rise to each claim or loss.

Upload file:

17.

Is any principal, director, partner, consultant, or employee, after enquiry, aware of any circumstances which might:

a) )Give rise to a claim against the Proposer or his/her predecessors in business or any of the present or former partners, principals, directors, consultants or employees?

Yes No

b) Result in Proposer or his/her predecessors in business or any of the present or former partners, directors, consultants employees, or principals incurring any losses or expenses which might be within the terms of this cover?

Yes No

c) Otherwise affect the Company’s consideration of this insurance? Yes No

If ‘yes’ in any case, please attach separate sheet providing full details.

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IT IS AGREED THAT IF SUCH FACTS, CIRCUMSTANCES OR SITUATIONS EXIST, WHETHER OR NOT DISCLOSED, ANY CLAIM ARISING FROM THEM IS EXCLUDED FROM THIS PROPOSED COVERAGE

GENERAL INSURANCE INFORMATION

18.

Has any insurer, in respect of the risks to which this proposal relates, ever:

a) declined a proposal, refused renewal or terminated any insurance? Yes No

b) declined an insurance claim by the Proposer or reduced its liability to pay an insurance claim in full (other than by application of an excess)?
Yes No

If Yes, - Please provide details of their activities and estimated annual payments:

DECLARATION

I, being a [Partner, Principal, Director] of the Proposer, hereby declare and warrant: -

I am authorised to complete this Proposal on behalf of the Proposer; and;
I have read and understand my obligations of duty of disclosure under the Insurance Contracts Act 1984 and have made enquires to ensure all answers to the questions contained in this Proposal are true and correct to the best of my knowledge and belief and that no information whatsoever has been withheld; and
I understand that the submission of this Proposal does not bind or obligate any party to enter into a binding contract of insurance.
I, agree to the above terms * Yes

Note: If insurance terms are provided to the Proposer, and the Proposer accepts the terms and wishes to proceed with the insurance cover, the Proposer may be required to physically sign a copy of the Proposal before insurance cover is provided.