Insured Details

Insured Name *

Phone *

Contact Name *

Email Address *

ABN *

Website

Number of Directors / Principals *

Number of Employees *

Date of Establishment *

What date do you require coverage by? *

Address *

Street Address *Street address line 2

City *

State *Please selectACTNSWNTQLDSATASVICWA

Postcode *

CountryPlease selectAfghanistanAlbaniaAlgeriaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiComorosCongo (Brazzaville)CongoCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast Timor (Timor Timur)EcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambia, TheGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea, NorthKorea, SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint VincentSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamYemenZambiaZimbabwe

Business Activity

Please provide a thorough description of your exact business activities *

Please provide an approximate percentage of income based on the training or service you provide (must add up to 100%) *

Accredited Training

Non-Accredited Training

Registered Training / Organisation Auditing

Education Consulting Services

Training Consulting Services

Learner Driver Training

Other Professional Services

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Training Specifications

Please provide an approximate percentage of income for the following groups of training (must add up to 100%) *

Group A - No Physical ComponentClassroom & online/distance education training with no physical component

Group B - Minor Physical ComponentClassroom training & online/distance education with minor physical component

Group C - Indoor Physical ComponentIndoor training where a physical component exists

Group D - Outdoor Physical ComponentOutdoor training where minor to major physical components exist

Group E - OtherOther training that does not fit any of the above groups

Please provide details on the type of training and the environment where the training is held plus any safety precautions in place *

What is the maximum height training takes place at? *

Trainer to Trainee Ratio (e.g. 1:10 = 1 trainer to 10 trainees) *

Is the training cordoned off with appropriate signage? *

YesNo

Are trainees attired in protective clothing and are PPE guidelines followed during training? *

YesNo

What machinery is used for training and who owns the machinery? *

Does the training occur on the insured's premises or third-party property? *

Insured's PremisesThird-Party PropertyBoth

Insured's Premises

Third-Party Property

Is an induction course presented before training commences *

YesNo

Coverage & Additional Information

Limit of Professional Indemnity required *None$1,000,000$2,000,000$5,000,000$10,000,000

Limit of Public & Products Liability required *None$5,000,000$10,000,000$20,000,000

Do you have ASQA registration in respect to the accredited training course you provide? *

YesNo

Are you qualified in this industry with a minimum of 3 years experience? *

YesNo

Are you a member of a professional association? *

YesNo

Please provide your actual total revenue or turnover for the previous financial year (enter '0' if not applicable)

Total revenue from the last financial year *

Total revenue for the current financial year *

Total revenue earned overseas from the last financial year *

Total revenue earned overseas for the current financial year *

Do you have a risk management program/protocol in place? *

YesNo

What measures do you have in place for mitigating risk?

Do you engage contractors and/or sub-contractors? *

YesNo

Do you require cover for contractors and/or sub-contractors? *

YesNo

Do you require cover for students placed into practical work experience (workforce) as a prerequisite of completing their qualification? *

YesNo

What professional services are trainees completing whilst on placement and what fees are incurred?

Where are the trainees' placements and for what duration?

How many students per year undertake placements?

Are students under constant supervision whilst placement is occurring?

YesNo

For the purpose of stamp duty, please confirm the percentage of revenue earned in each state (must add up to 100%) *

ACT

NSW

NT

QLD

SA

TAS

VIC

WA

Overseas

Are you a small business eligible for exemption from paying NSW stamp duty on certain types?

YesNo

The NSW Government has created a new small business stamp duty exemption in the Duties Act 1997 (NSW) (the Act) for eligible insurance acquired on or after 1st January, 2018. If you are uncertain whether you are classified as a small business we recommend you seek professional advice and speak to your accountant or financial adviser.

Claims Information

Has any claim been made against the proposer or any principal, partner or director, consultant or employee in respect to the risks this proposal relates to? *

YesNo

Please provide details

Has the proposer or any principal/partner/director/consultant or employee incurred any other loss or expense which might be within the terms of coverage? *

YesNo

Please provide details

Is any principal/partner/director/consultant or employee, after enquiry, aware of circumstances which may give rise to a claim against the proposer or his/her predecessors in business or any of the present or former partners, principals, directors, consultants, or employees? *

YesNo

Please provide details

Is any principal/partner/director/consultant or employee, after enquiry, aware of circumstances which result in the proposer or his/her predecessors in business or any of the present of former partners, directors, consultants, employees, or principals incurring any losses or expenses which might be within the terms of this cover? *

YesNo

Please provide details

Is any principal/partner/director/consultant or employee, after enquiry, aware of circumstances which otherwise affect the company’s consideration of this insurance? *

YesNo

Please provide details

General Insurance Information

Has any insurer, in respect of the risks to which this proposal relates, ever declined a proposal, refused renewal, or terminate any insurance and/or declined an insurance claim by the proposer of reduced its liability to pay an insurance claim in full (besides application of an excess? *

YesNo

Please provide details

Have you ever, either alone or jointly with others been declared bankrupt or subject to any form of insolvency administration (e.g., liquidation or receivership)? *

YesNo

Please provide details

Declaration

I/We the undersigned duly authorised person(s) declare that:

• I am / we are authorised by each of the Proposers to sign this Proposal Form; and

• The above statements are correct, true and complete; and

• No information material to this Proposal Form has been withheld; and

• I/we have read the important facts which you have put before me / us and I / we understand the advice given in relation to necessary and detailed enquiries in order to comply with the duty of disclosure; and

• I / we undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance; and

• I / we undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance; and

• I / we acknowledge that the Insurer relies on the information and representations in this Proposal Form and otherwise made by me / us in relation to this insurance.

Full Name *

Company *

Date *

Signature *

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