On-line Directors and Officers Indemnity Insurance

Thank you for considering our on-line Directors and Officers Indemnity insurance service.   Because Greater National Group is an insurance broker, not an insurance company, we will process your application with major insurance companies in order to find the right Directors and Officers Indemnity insurance for you.

Please fill in the following form as fully as possible, then click 'submit' at the end of the form.
You can use the TAB key to move to the next field. We will respond with your terms as soon as we have researched the market for the right available deals that fit your requirements.

Limit of Liability Required:
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?
Yes No
If Yes, please give full details:
Expiry Date:
Insurance Company:
Indemnity Limit
3. Please give a clear description of the company's activities:
4. Legal status of the Corporation:
Listed Private Non-Profit Unlisted Co-op/Mutual
Other, please specify
5. Date the Corporation commenced the business (as referred above)
6. Is the Corporation a subsidiary of another entity?
Yes No
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?
Yes No
If Yes, please provide the name of the share holder and the percentage held:
Director/Executive Officer Details
8. Are any of the directors currently members of any professional association (e.g. Australian Institute of Company Directors)
Yes No
If Yes, please provide details:
9. Does the Corporation have an audit or compliance committee?
Yes No
10. Has any director of executive officer of the Corporation been declared bankrupt?
Yes No
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 ?
Yes No
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?
Yes No
If Yes, please provide details:
Corporation Insurance 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?
Yes No
If Yes, please provide details
14. Corporation's Financial Information
  This Year Last Year
Current Assets
Total Current Assets    
Non-current Assets
Total Assets
Current Liabilities
Total Current Liabilities    
Non Current Borrowings
Other non-current liabilities
15. Are the accounts of the Corporation consolidate Accounts?
Yes No
16. If the accounts audited?
Yes No
17. If the accounts have been audited, Is the audit report qualified?
Yes No
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?
Yes No
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?
Yes No
If Yes, please provide details
20. Are there any contingent liabilities or events subsequent to the balance date?
Yes No
21. Claims
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?
Yes No
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?
Yes No
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?
Yes No
If Yes to any of the above questions please include details:
22. Optional Extensions
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:
Yes No
Prospectus Liability Cover:
Yes No
Joint Venture Cover:
Yes No
Pre-Aquisition Liability:
Yes No
USA & Canada Jurisdiction:
Yes No

Duty of Disclosure:
Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?
Yes No
If so, please provide details:
I/We hereby declare that:
My/Our attention has been drawn to the Important Notices accompanying this form and further I/we have read these notices carefully and acknowledge my/our understanding of their content. The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this form and the inception date of the insurance to which this relates I/we shall give immediate notice thereof. I/We authorise GNG and the Insurer to collect or disclose any personal information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact and the Privacy Policy. I/We also confirm that I/we am/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this form and I/we complete this form on their behalf.
Any other comments, requests or relevant information you need to add:
Contacting you about your quote:
In order to select the most appropriate cover for you, it may be important to discuss quote details in person. Please leave a contact phone number and best time to call to facilitate this.
Your full name:
Company/Business/Name of Applicant to be Insured:
Your phone number (please include area code):
Your mobile phone number:
Best time(s) to call:
Please send my quote by (select at least one):
email phone fax mail
Your email address:
Your website address:
Your fax number:
Your postal address: