[Your company name, ABN, address, phone number, fax number, website, email]
VOLUNTARY WORKERS PERSONAL ACCIDENT PROPOSAL
Important Notices
Please read the following before proceeding to complete this proposal form.
Completed proposals should not be forwarded to the below privacy contact details. Completed proposals should be forwarded to your insurance broker or [Your company name] at [Your company email address].
[Your company name, ABN, AFSL] acts as an agent on behalf of [Your insurance company, ABN, AFSL], the insurer of this product.
General Insurance Code of Practice
[Your insurance company] is a signatory to the General Insurance Code of Practice. The Code aims to raise standards of service between insurers and their customers.
For any information about the Code, including a copy of the Code, contact [Your insurance company] on [Your 1300 number] or visit [Your Code website].
Duty of Disclosure
Whether You are entering into a Policy for the first time or are proposing to renew, vary, extend or reinstate a Policy You have a duty of disclosure:
Your Duty of Disclosure for New Policies
When answering Our questions You must be honest and You have a duty under law to tell Us anything known to You, and which a reasonable person in the circumstances, would include in the answer to the question. We will use the answers in deciding whether to insure You and anyone else to be insured under the Policy, and on what terms.
Your Duty of Disclosure for Renewals
If You have already entered into a Policy and You are proposing to renew, vary, extend or reinstate the Policy Your duty of disclosure changes. You have a duty to tell Us of everything that You know, or could reasonably be expected to know, that os relevant to Our decision to insure You and to the terms of that insurance. If You are not sure whether something is relevant You should inform Us anyway.
Who Needs to Tell Us?
It is important that You understand You are answering Our questions in this way for Yourself and anyone else that You want to be covered by the Policy.
What You Are Not Required to Disclose
Your duty does not require discloser of matters that:
If You Do Not Tell Us
If You do not answer Our questions in this way or disclose everything You know, We may reduce or refuse to pay a claim, or cancel the Policy. If You answer Our questions fraudulently, We may refuse to pay to pay a claim and treat this Policy as never having been in force.
Privacy Statement
Both [Your insurance company name and your company name] respect your privacy. Any personal information provided by you will be treated in accordance with the Privacy Act 1988 (Cth). This privacy notification provides a summary of how [Your insurance company name and your company name] treat your personal information.
[Your insurance company name and your company name] primarily collect your personal information via this form to assess your request for insurance and to administer your Policy but may also use this information to settle an insurance claim, provide other insurance services as requested by you, and also to notify you about other services or promotions from time to time.
If you do not provide the information requested you may breach your duty of disclosure, your application may not be capable of being accepted, additional conditions may be imposed on any cover provided or your Policy may not be able to be administered.
In order to provide its insurance services [Your insurance company name and your company name] may need to disclose your personal information to third parties including, but not limited to: agents, underwriters, advisors and brokers; claims management and other service providers; claims adjusters, loss assessors and other claims investigators; lawyers; reinsurers and reinsurance brokers; and the Financial Ombudsman Service, or as required by law (for a full list see [Your insurance company name and your company name] Policies).
In the event of the claim, [Your insurance company name and your company name] may disclose your personal information (including sensitive information) to overseas reinsurers for the purpose of assessing your claim. [Your insurance company name and your company name] will only share information with third parties where [Your insurance company name and your company name] reasonably believe it is necessary in assessing your insurance claim and in providing the products and services requested.
[Your insurance company name and your company name] Privacy Policies contain information about how to access and correct the personal information about you and also how to complain about a breach of privacy. If you would like additional information about privacy or would like to obtain a copy of the Privacy Policies, please contact [Your insurance company’s] Privacy Officer by
· Tel: xx xxxx xxxx
· Fax: xx xxxx xxxx
· Email: xxxx@xxxx.com
· Mail: xxxxx etc.
You can download a copy of [Your insurance company’s] Privacy Policy by visiting [Your insurance companies Privacy Policy website link].
You can also download a copy of [Your company’s] Privacy Policy by visiting [Your company’s Privacy Policy website link]
Taxation Information
If Insured Persons are not registered for GST, in the event of a claim We will reimburse the Insured Persons the GST component in addition to the amount that We pay. The amount that the Insured Person is liable to pay under this Policy will be reduced by the amount of any tax credit that the Insured Person is or may be entitled to claim for the supply of goods or services covered by that payment.
If you are entitled to an input tax credit for the Premium you must inform us of the extent of that entitlement at or before the time you make a claim under this Policy. We will not indemnify you for any GST liability, fines or penalties that arise from or are attributable to your failure to notify us of your entitlement (or correct entitlement) to an input tax credit on the Premium.
If you are liable to pay an Excess under the Policy, the amount payable will be calculated after deduction of any input tax credit that you are or may be entitled to claim on payment of the Excess.
If You or Insured Persons are unsure about the taxation implications of this Policy, You should seek advice from Your accountant or tax professional.
Don't Prevent Our Right of Recovery
The Liability Policy contains a provision which states that if You surrender Your right to seek recovery from another party a loss covered by the Policy, We have a right to reject any claim from You in relation to that loss.
VOLUNTARY WORKERS PERSONAL ACCIDENT PROPOSAL
Details of the Insured
Name of Insured:
Postal Address: Suburb State Postcode
Telephone Numbers: Home Mobile
Email Address:
Details of the Event
Event date: Time Start: Finish:
Event Address: Location Name:
Cover to Commence: Cover to Expire:
Number of Guests: Indoors or Outdoors:
Nature of event to be insured:
General History
Has any insurer ever declined to insure You or declined to renew any of Your Insurances or asked that You agree to special terms or conditions? Yes/No
If Yes, please supply details:
Are You aware of any circumstances which may give rise to a Claim in the future? Yes/No
If Yes, please supply details:
Do You carry out any activities outside of Australia? Yes/No
If Yes, please supply details:
Claims History
Have any claims been made against You in respect of Your legal liability for injury or damage in the past 5 years? Yes/No
If Yes, please supply details:
Date of Incident Nature of Injury/Damage Amount claimed
Voluntary Workers Details
Please advise the activities Your volunteer workers will be performing:
1. Performers - please advise number of volunteers undertaking this type of activity, and types of performing activities;
2. General Event Staff - Please advise number of volunteers undertaking this type of activity, and types of general event activities being undertaken:
3. Construction related - please advise the number of volunteers undertaking this type of activity, and types of construction related activites being udnertaken (including details of any rigging, stage construction, seating construction, infrastructure work etc. ):
4. Other Activities - please advise full details of any other activities being undertaken by volunteers not included in the above:
Has any person ever been injured whilst doing voluntary work for You? Yes/No
Are there any exceptional circumstances relating to the risk to be insured that You have not already told Us about, and that You know or should know may affect Our decision to insure You? Yes/No
If Yes, please give relevant information:
Total number of volunteers registered with Your event:
Will any volunteers be undertaking security related work at the event? (note this is an exclude activity under the Policy): Yes/No
Declaration
I/We
(a)declare that:
(i) the answers and information given by me/us in this proposal are true and correct in all respects and that no information has been withheld which would affect [Your company's name] decision about accepting this insurance;
(ii) where answers in this Proposal are not my/our own handwriting, they have been checked by me/us and I/we agree they are correct;
(iii) I/we have read and understood the clauses detailed under the Important Notices of this Proposal;
(iv) if there was insufficient space to fully answer any questions, we have attached supplementary pages providing the additional information required;
(v) I/we authorise [Your company name] to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to these insurance covers, and any other insurances held by me/us and claims under those insurances;
(vi) I/we understand that if this Proposal is accepted, my/our insurance cover will be subject to the terms and conditions set out in the Applicable Policy;
(vii) I/we further acknowledge that [Your company name], their agents or employees reserve the right to decline this proposal.
(b) authorise [Your company name and Your insurance company name] to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to these insurance covers, and any other insurances held by me/us and claims under those insurances;
(c) understand that, if this Proposal is accepted, my/our insurance cover will be subject to the terms and conditions set out in the Arena Voluntary Workers Personal Accident Product Disclosure Statement and Insurance Policy;
(d) acknowledge that [Your company name and/or Your insurance company name], their agents or employees reserve the right to decline this Proposal.
Proposer's Signature:
Date: / /
Proposer's Name:
Proposer's Title:
Completed proposals should be forwarded to your insurance broker or [Your insurance company] at [Your insurance company email]