On-line Recruitment Professional Indemnity Insurance


Thank you for considering our on-line professional 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 professional 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.


Amount of Cover
1a. Please select the preferred level(s) of indemnity for Public & Products Liability:
$5,000,000 each occurrence
$10,000,000 each occurrence
$20,000,000 each occurrence
Other $
1b. Please select the preferred level(s) of indemnity for Professional Liability:
$1,000,000 each occurrence
$2,000,000 each occurrence
$5,000,000 each occurrence
Other $
Details of Proposer
2a. Title of company (including all Subsidiary Companies) and T/as names applicable:
2b. Prinicpal location address:
2c. Postal address:
2d. Number of locations in Australia:
Overseas:
2e. Date of company incorporation:
ABN:
2f. Please provide a full description of your business activities (if Subsidiary companies differ to Parent company, please state and also reference to which company(s) applicable):

Principally that of a personnel agency prodviding employees, staff, contractors, sub-contractors and/or consultants which may be permanent, temporary, casual, contracted and/or sub-contracted and/or on-hired and all ancillary activities including business consulting services, the provision of professional advice, property owners and/or occupiers.
Insured's business includes the business of any person or company (or firm) to whom the services of employees, staff, contractors, sub-contractors and/or consultants may be provided.
Foreign Operations / Companies
3. Does the proposer have any foreign operations and/or companies which are to be included?
Yes No
If yes, please provide locations and full descriptions of activities:
Principals' & Directors' / Ownership
4.
Name of Shareholder Percentage of
Shares Owned
%
%
%
%
4b.
Name Date Appointed Qualifications Role Age
Previous Business - (Optional Extension)
5. Is cover for a Director's previous business required?
Yes No
If yes, please provide names(s) of the company(s) and full descriptions of activities:
Proposer's Operations
6a. Please indicate the total number of Principals and operation staff currently employed within the business:
Currently Projected
(next 12 months)
Principals:
Qualified Consultants & Managers:
Staff, (other than Office Administration support):
Office & Administration support staff:
Juniors:
Others:
TOTAL:
6b. Please indicate the operational wages/salaries for the Principals and operational staff within the business:
Last 12 Months Projected
(next 12 months)
$ $
6c. Please indicate (FEES) for PERMANENT placements:
Last 12
Months		 Projected
(next 12 months)
Clerical / Secretarial & Office Support $ $
Call Centre Operators $ $
Production / Manufacturing Operatives $ $
Accountants $ $
Architects $ $
Engineers $ $
Lawyers $ $
Nurses $ $
Hospitality $ $
IT & T $ $
Logistics $ $
Mining $ $
Other
$ $
Total $ $
6d. Please indicate the gross wages for TEMPORARIES (PAYG Employees):
Last 12
Months		 Projected
(next 12 months)
Clerical / Secretarial & Office Support $ $
Call Centre Operators $ $
Production / Manufacturing Operatives $ $
Construction &/or Trades $ $
Drivers - truck, forklifts other vehicles etc
(please refer to Optional Extension 11)		 $ $
Engineers - Welding $ $
Engineers - Factory $ $
Engineers - White Collar $ $
Accountants $ $
Architects $ $
Lawyers $ $
Nurses $ $
Hospitality $ $
IT & T $ $
Logistics $ $
Mining (Miners) $ $
Other
$ $
Total $ $
6e. Please indicate the gross wages for ABN / Pty Ltd CONTRACTORS / SUB-CONTRACTORS:
Last 12
Months		 Projected
(next 12 months)
Clerical / Secretarial & Office Support $ $
Call Centre Operators $ $
Production / Manufacturing Operatives $ $
Construction &/or Trades $ $
Drivers - truck, forklifts other vehicles etc
(please refer to Optional Extension 11)		 $ $
Engineers - Welding $ $
Engineers - Factory $ $
Engineers - White Collar $ $
Accountants $ $
Architects $ $
Lawyers $ $
Nurses $ $
Hospitality $ $
IT & T $ $
Mining (Miners) $ $
Other
$ $
Total $ $
6f. Does your business have any other income source(s) ie. provide training?
Yes No
If yes, please provide activities:
Activity Last 12
Months		 Projected
(next 12 months)
$ $
$ $
$ $
$ $
$ $
Total $ $
Contractual Liability
7. Have you the proposer assumed any obligations under any contracts or agreements including Hold Harmless or indemnification provision regardless of fault or waived rights of recovery against another party other than the Principal, or under any other activity of the Proposer?
Yes No
If yes, please provide details
Screening
8. Do you individually screen all employees and Temporary and/or Contract staff?
Yes No
If yes, please indicate procedures implemented
Interviews
Reference Checking
Other
Prior Insurance
9. Are you currently insured under a Public Liability Policy or have you ever had this type of insurance before?
Yes No
If yes, please provide details
Insurer Expiry Date Limit of Liability
Insurance Claims & Circumstance History
10. Have you ever had an Insurer:
10a. Decline a Proposal?
Yes No
10b. Impose Special Terms?
Yes No
10c. Decline to Renew your insurance?
Yes No
10d. Cancel your insurance?
Yes No
If yes, please provide details including date & description
10e. Are any of the Directors, Officers, Company Secretary, Partners or Principals aware of any fact, circumstance, past or present, which may give rise to a claim?
Yes No
If yes, please provide details including date & description
10f. Has any past or present Directory, Partner, Officer, Company Secretary or Employee of the Company ever been declared bankrupt, had any fine or penalty imposed or been subject to any enquiry in their capacity as a Director, Officer, Company Secretary or Employee of the Company?
Yes No
If yes, please provide details including date & description
10g. Have any claims ever been made against the Company or any of its Subsidiaries, any of its past or present Directors, Offices, Company Secretary, Partners or Principals in respect of Public or Products Liability?
Yes No
If yes, please provide details
10h. During the last 5 years has any aquisition or merger taken place involving the Company or any Subsidiary?
Yes No
If yes, please provide details including date & description
10i. During the last 5 years has the capital structure of the Company or Parent Company changed?
Yes No
If yes, please provide details including date & description
10j. Is the Company aware of any aquisition, tender offer or merger pending or under consideration?
Yes No
If yes, please provide details including date & description
Stamp Duty
11. For the purposes of calculating the Stamp Duty and GST charges, please provide a breakdown of the number of locations of the Company operating in each State, Territory or Overseas?
NSW  VIC  QLD  SA  WA  TAS  NT  ACT  O/S  Total
                 
12. Supporting Documentation
Please email/fax/mail the following documentation in support of your application:
  • Any offer Document/Listing Particulars published in the last 12 months
  • Any brochures setting out the Company's profile
  • Your Standard Terms of Business (for the supply of temporary/contract employees)
  • Copies of any documented procedures in relation to the screening & interviewing process for employees & Temps.
  • A copy of your Time Sheet given out to your temporary employees
  • If not contained on your website, a brief resume for each Principal and/or Director.


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: Date of Commencement
Are you registered for GST purposes?
Yes No
ABN:
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:
Country: