1a.
State the Limit of Indemnity required:
$
1b.
What excess you wish to pay towards a claim:
$
2.
Are you currently insured for directors and officers insurance?
If Yes , please give full details:
Expiry Date:
Insurance Company:
Indemnity Limit
$
Excess
$
Premium
$
3.
Please give a clear description of the company's activities:
4.
Legal status of the Corporation:
5.
Date the Corporation commenced the business (as referred above)
6.
Is the Corporation a subsidiary of another entity?
If Yes , please provide details:
7.
Is there any shareholder holding, directly or beneficially, 10% or more of the ordinary share capital of the Corporation?
If Yes , please provide the name of the share holder and the percentage held:
8.
Are any of the directors currently members of any professional association (e.g. Australian Institute of Company Directors)
If Yes , please provide details:
9.
Does the Corporation have an audit or compliance committee?
10.
Has any director of executive officer of the Corporation been declared bankrupt?
If Yes , please provide details:
11.
Has any director or executive officer of the Corporation been a director of an organisation placed in receivership,
liquidation or provisional liquidation ?
If Yes , please provide details:
12.
Has there ever been any acquisition or disposal, merger or takeover undertaken by the Corporation or any subsidiaries in the last 24 months?
If Yes , please provide details:
13.
Has the Corporation or subsidiary ever been refused this type of insurance, or had similar insurance cancelled,
or decline to renew, or had any special terms imposed?
If Yes , please provide details
14.
Corporation's Financial Information
15.
Are the accounts of the Corporation consolidate Accounts?
16.
If the accounts audited?
17.
If the accounts have been audited, Is the audit report qualified?
If Yes , please provide details
18.
Have the accounts been certified by the directors as representing
a true and fair view of the company's financial position?
19.
Is there any subsequent information of a material nature not disclosed in the financials that could effect the financial
position, capital structure or operation of the Corporation?
If Yes , please provide details
20.
Are there any contingent liabilities or events subsequent to the balance date?
21a.
If an insurance similar to that now proposed had been, or were now,
in effect would any claim which had been made, or which is now pending
against any person proposed for insurance, have fallen within the scope
of such insurance?
21b.
Is any person proposed for insurance aware, after enquiry of any circumstances
or incident which he/she has reason to suppose might afford grounds
for any future claim such as would fall within the scope of the proposed
insurance?
21c.
Has there been, or is there now pending, any prosecution of the Corporation
of its subsidiaries or any official investigation, examination or enquiry
of the Corporation or its subsidiaries under the Corporations Act, trade
practices Act, Occupational Health & Safety Legislation or any other
statute?
If Yes to any of the above questions please include details:
22a.
Outside Directorships - This extension provides indemnity to Directors
and Officers who currently represent the Corporation's interest in any
nominated non-profit organisation.
Please provide a list of nominated non-profit organisations to be covered by
this extension and any claims details (see Question 7) for each organisation.
22b.
Do you require the following extensions to your policy?
Current Outside Directorships other than Non-Profit Organisations:
Prospectus Liability Cover:
Joint Venture Cover:
Pre-Aquisition Liability:
USA & Canada Jurisdiction: