Professional Indemnity

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  1. This policy is only available to Australian domiciled persons.
  2. Where did you hear about Action Entertainment Insurance?
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  3. Have you previously spoken to an Action Representative regarding this quote?(*)
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  4. Name of representative?
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  5. Name of Insured(*)
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  6. ABN(*)
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  7. To what extend (%) is an Input Tax Credit being claimed?(*)
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  1. Are you completing this proposal as a client or broker on behalf of the client?(*)
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  2. Brokerage Name (*)
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  3. Contact Name(*)
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  4. Postal Address(*)
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  5. Suburb(*)
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  6. State(*)
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  7. Postcode (*)
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  8. Phone Number(*)
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  9. Fax Number
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  10. Email Address (*)
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  11. Website Address
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  12. Clients Address (*)
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  13. Clients Website Address
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  1. Period of Cover
  2. From Date(*)
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  3. Limit of cover required:(*)
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  4. Please provide detailed description of your professional business which is to be covered by this policy(*)
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  5. Please list all locations from which the Insured operates(*)
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  6. Do you conduct any business in North America?(*)
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  7. Please provide details
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  8. Please provide a breakdown of your gross fees / income for the last financial year and the current financial year.
  9. Business 1
  10. Professional Business
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  11. Percentage Split (%)
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  12. Last Financial year’s Gross Fees ($)
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  13. Current Financial Year’s Gross Fees ($)
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  14. Business 2
  15. Professional Business
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  16. Percentage Split (%)
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  17. Last Financial year’s Gross Fees ($)
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  18. Current Financial Year’s Gross Fees ($)
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  19. Business 3
  20. Professional Business
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  21. Percentage Split (%)
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  22. Last Financial year’s Gross Fees ($)
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  23. Current Financial Year’s Gross Fees ($)
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  24. Add another business?
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  25. Business 4
  26. Professional Business
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  27. Percentage Split (%)
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  28. Last Financial year’s Gross Fees ($)
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  29. Current Financial Year’s Gross Fees ($)
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  30. Add another business?
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  31. Business 5
  32. Professional Business
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  33. Percentage Split (%)
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  34. Last Financial year’s Gross Fees ($)
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  35. Current Financial Year’s Gross Fees ($)
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  36. Add another business?
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  37. Business 6
  38. Professional Business
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  39. Percentage Split (%)
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  40. Last Financial year’s Gross Fees ($)
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  41. Current Financial Year’s Gross Fees ($)
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  42. Add another business?
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  43. Business 7
  44. Professional Business
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  45. Percentage Split (%)
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  46. Last Financial year’s Gross Fees ($)
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  47. Current Financial Year’s Gross Fees ($)
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  48. Add another business?
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  49. Business 8
  50. Professional Business
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  51. Percentage Split (%)
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  52. Last Financial year’s Gross Fees ($)
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  53. Current Financial Year’s Gross Fees ($)
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  54. In respect of gross fees/income for the last financial years, please provide a breakdown by state.
  55. NSW
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  56. VIC
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  57. QLD
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  58. SA
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  59. WA
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  60. TAS
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  61. ACT
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  62. NT
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  63. Overseas
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  64. Date that Business was established?(*)
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  65. Has the Business been profitable for the last two years?(*)
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  66. Please attach details
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  67. Please provide details of your 5 largest contracts or projects undertaken.
  68. Project 1
  69. Project Description/ Contract
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  70. Fees/Income ($)
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  71. Project Value ($)
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  72. Date Completed (DD/MM/YY)
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  73. Project 2
  74. Project Description / Contract
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  75. Fees/Income ($)
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  76. Project Value ($)
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  77. Date Completed (DD/MM/YY)
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  78. Project 3
  79. Project Description / Contract
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  80. Fees/Income ($)
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  81. Project Value ($)
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  82. Date Completed (DD/MM/YY)
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  83. Project 4
  84. Project Description / Contract
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  85. Fees/Income ($)
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  86. Project Value ($)
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  87. Date Completed (DD/MM/YY)
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  88. Project 5
  89. Project Description / Contract
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  90. Fees/Income ($)
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  91. Project Value ($)
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  92. Date Completed (DD/MM/YY)
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  93. Does the business derive more than 30% of its total fees from services provided to any one client?(*)
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  94. Please provide details
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  95. Do you require cover for incorporated Joint Ventures?(*)
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  96. Please provide details
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  1. Employee Information
  2. Please provide the following;
  3. Total Number of Employees(*)
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  4. Number of Principals, Directors & Partners
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  5. Number of Qualified Employees
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  6. Please provide the following details for each of the Insured’s principals, partners, directors and qualified staff.
  7. Insured Person 1
  8. Name
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  9. Age
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  10. Qualifications
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  11. Years Experience
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  12. Memberships of professional associations
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  13. Insured Person 2
  14. Name
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  15. Age
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  16. Qualifications
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  17. Years Experience
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  18. Memberships of professional associations
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  19. Insured Person 3
  20. Name
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  21. Age
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  22. Qualifications
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  23. Years Experience
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  24. Memberships of professional associations
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  25. Add another Insured Person?
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  26. Insured Person 4
  27. Name
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  28. Age
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  29. Qualifications
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  30. Years Experience
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  31. Memberships of professional associations
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  32. Add another Insured Person?
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  33. Insured Person 5
  34. Name
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  35. Age
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  36. Qualifications
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  37. Years Experience
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  38. Memberships of professional associations
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  39. Add another Insured Person?
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  40. Insured Person 6
  41. Name
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  42. Age
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  43. Qualifications
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  44. Years Experience
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  45. Memberships of professional associations
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  46. If previous Business cover is required, please completed the following details:
  47. Name of Principal, Director or Partner 1
  48. Name of Principal, Director or Partner requiring this cover
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  49. Date left Previous Business (use calendar to select date)
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  50. Are You aware of any claims or circumstances against the previous business? If so, please provide details
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  51. Name of Principal, Director or Partner 2
  52. Name of Principal, Director or Partner requiring this cover
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  53. Date left Previous Business
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  54. Are You aware of any claims or circumstances against the previous business? If so, please provide details
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  55. Name of Principal, Director or Partner 3
  56. Name of Principal, Director or Partner requiring this cover
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  57. Date left Previous Business
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  58. Are You aware of any claims or circumstances against the previous business? If so, please provide details
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  59. Add another Principal, Director or Partner
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  60. Name of Principal, Director or Partner 4
  61. Name of Principal, Director or Partner requiring this cover
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  62. Date left Previous Business
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  63. Are You aware of any claims or circumstances against the previous business? If so, please provide details
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  64. Add another Principal, Director or Partner
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  65. Name of Principal, Director or Partner 5
  66. Name of Principal, Director or Partner requiring this cover
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  67. Date left Previous Business
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  68. Are You aware of any claims or circumstances against the previous business? If so, please provide details
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  69. Add another Principal, Director or Partner
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  70. Name of Principal, Director or Partner 6
  71. Name of Principal, Director or Partner requiring this cover
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  72. Date left Previous Business
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  73. Are You aware of any claims or circumstances against the previous business? If so, please provide details
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  74. Do you engage consultants, sub-contractors or agents(*)
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  75. What % of the Applicant’s total fees are derived from contractors?
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  76. Are they required to carry their own Professional Indemnity Insurance?
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  77. Does the Applicant enter any hold harmless agreements or otherwise waive any legal rights or entitlements which may be available against such consultant, sub-contractors or agents?(*)
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  78. Please attach copy of agreement
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  1. Risk Management
  2. Do you provide written disclaimers with any advice provided to your clients? (*)
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  3. Please provide example
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  4. Are verbal reports or advice always confirmed in writing?(*)
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  5. Please advise what percentage of reports fall in to this category(*)
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  6. Do you use standard written service agreements for all advice provided?(*)
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  7. Do you provide warranties or guarantees?(*)
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  8. Do you ever assume liability for others by contract?*(*)
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  9. Please provide copy of contract(*)
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  10. Do you describe services in a brochure or other promotional material?* (*)
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  11. Please attach a sample
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  1. Claims and Circumstances
  2. Is the Applicant, it’s directors, officers and/or any other proposed insured person aware of any facts or circumstances that might afford valid grounds for any future claim(s) that would fall within the scope of the proposed coverage or which indicate the probability of such Claims?(*)
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  3. Please provide details.
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    Note: if such facts of circumstances exist, any claim, action or proceeding arising therefrom is excluded from the proposal coverage.
  4. Have you ever been refused this type of cover or had a similar policy cancelled or non-renewed?(*)
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  5. Please provide details
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  6. Do you currently have professional indemnity insurance?(*)
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  7. Please advise the name of Insurer, Limit of Indemnity, Deductible and Policy Period
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  8. Announced Changes
  9. Has the Applicant publicly revealed that it has under consideration at the present time any acquisitions, tender offers or mergers?(*)
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  10. Please provide details
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  11. Are there at present any proposals of which you are aware relating to its acquisition by any other company?(*)
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  12. Please provide details
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  13. Prior Knowledge/Warranty
  14. Have you or any person proposed coverage given notice under the provision of any prior or current Professional Indemnity insurance policy or similar insurance of facts or circumstances which might give rise to a claim being made against any such person?(*)
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  15. Please provide details
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  16. Have any loss payments been made on behalf of any Applicant or any person proposed for coverage under any Professional Indemnity insurance policy of similar insurance?(*)
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  17. Please provide details
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  18. Have there been or is there now pending against any person proposal for coverage under this Professional Indemnity insurance policy a claim against them in their capacity as such?(*)
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  19. Please provide details
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    Note: any such claim will be excluded from the proposed coverage.
  1. Disclaimer

    Privacy Policy

    At Action Entertainment Insurance Pty Ltd Corporate Representative No. 237473 as an authorised representative of Action Insurance Brokers P/L AFS 225047, we are committed to protecting your privacy in accordance with the Privacy Act 1988 (Cth) and the Australian Privacy Principles. This Privacy Policy describes our current policies and practices in relation to the collection, handling, use and disclosure of personal information. It also deals with how you can complain about a breach of the privacy laws and how you can access the personal information we hold and how to have that information corrected.

    Please visit https://www.entertainmentinsurance.net.au/privacy-policy to read our full privacy policy.

    Your Duty of Disclosure

    When entering into a contract of general insurance you need to tell us

    Before you enter into a contract of general insurance with us, you have a duty, under the Insurance Contracts Act 1984, to disclose to us every matter that you know, or could reasonably be expected to know, is relevant to our decision whether to accept the risk of the insurance and, if so, on what terms.

    When entering into a subsequent or renewing a contract of general insurance

    You have the same duty to disclose any matter to us before you renew, extend, vary or reinstate a contract of general insurance, which may affect our decision to insure you.

    What you are not required to disclose

    Your duty does not require disclosure of any matter:

    1. 1.That diminishes the risk to be undertaken by us;
    2. 2.That is of common knowledge;
    3. 3.That we know or, in the ordinary course of our business, ought to know;
    4. 4.Where compliance with this duty is waived by us.

    Non disclosure and its consequences

    If you fail to comply with your duty of disclosure at law, and/or have not answered our questions honestly and not told us what you, as a reasonable person in the circumstances would have answered, we may be entitled to reduce our liability under the contract in respect of a claim or may cancel the contract.

    Fraudulent non disclosure and its consequences

    If your non disclosure is fraudulent, we may also have the option of avoiding the contract from its beginning.

    Subrogation

    You may prejudice your rights with regard to a claim if, without prior agreement from the Insurer, you make agreement with a third party that will prevent the Insurer from recovering the loss from that, or another party.

    Your policy contains provisions that either exclude the Insurer from liability or reduce their liability, if you have entered into any agreements that excludes your rights to recover damages from another party in relation to any loss, damage or destruction which would allow you to sustain a claim under this policy.

  2. Declaration:Any Person who, knowingly and with intent to defraud any insurance company or other person, files a proposal form insurance containing any false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime.

    By ticking this box you declare that to the best of your knowledge and belief that the statements set forth herein and all attachments hereto are true and immediate notice will be given should any of the above information alter between the date of this proposal and the proposed date of inception of the insurance. Although the submission of this proposal does not bind The Applicant or their directors, officers or other insured person to effect insurance, the Applicant agrees that this proposal and any attachments and the said statements herein shall be the basis of and will be incorporated in the policy should one be issued.

  3. Do you agree?(*)
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  4. I have read and understand the Statutory Notices:(*)
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  5. I have read and understand the Subrogation Clause(*)
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  6. Anti-Spam(*)
    Anti-Spam
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Action Entertainment Insurance Pty Ltd ABN 20 103 891 265 Corporate Representative No. 237473 as an authorised representative of Action Insurance Brokers P/L ABN 39 080 844 426 AFS 225047

Privacy Policy
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