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Community Association Club
Directors & Officers Insurance

AUSTRALIAN & NEW ZEALAND NATIONWIDE INSURANCE SERVICES
Sydney • Brisbane • Melbourne • Adelaide • Perth • Wellington • Auckland

Community Association Club - Directors & Officers Liability - Insurance

NEEDS ANALYSIS FORM

This form is designed to gather general information from which to present to various underwriters to obtain an indicative quote. You will most likely have to provide further information in due course.

If your Community Association Club's requirements exceed the scope of this form, please contact us for direct personal assistance Or phone 13-7442

Terms and Conditions

DETAILS OF APPLICANT -

Section 1


Your Contact Name

Name of the Association/Club (Hereinafter referred to as the "Organisation" in this Form)

Which State is your Organisation located in?

Date the Organisation commenced Operation?

Approximately how many members does the Organisation have?

ACTIVITIES OF THE ORGANISATION -

Section 2

a)	Principle Operation and Activities of the Organisation

b)	Does the Organisation provide legal aid services, financial services, computer or information services or other advisory services?	Yes No
	If Yes, please supply details

c)	Is the Organisation engaged in an form of research, development, experimentation or testing?	Yes No
	If Yes, please supply details

d)	Does the Organisation conduct any activity which evaluates or sets standards for the qualification and performance of others or the quality or products manufactured or sold?	Yes No
	If Yes, please supply details

e)	Does the Organisation issue any brochures or other promotional material describing its activities or services? If Yes, we my require copies later.	Yes No

f)	Does the Organisation promote, sponsor or provide any form of insurance to its members?	Yes No
	If Yes, does the Organisation act as an insurance agent?	Yes No
	If Yes, please supply details or such agencies including names of insurers and products offered.

g)	Does the Organisation conduct sport in Australia?	Yes No
	If Yes, please supply details of the nature and extent of your Organisation's sporting activities

h)	Does the Organisation conduct sport in any other country than Australia?	Yes No
	If Yes, please supply details of which country(s) and how often does the Organisation have sporting events outside of Australia?

THE ORGANISATION'S CURRENT INSURANCE COVER -

Section 3

	Does the Organisation presently carry, or has the Organisation ever carried, Association Liability or Directors and Officers Liability Insurance?		Yes No

	If Yes, please supply details

	What is the Expiry Date?

	What is the Limit of Indemnity Cover?		$

	Premium		$ OPTIONAL

THE ORGANISATION'S APPLICATION FOR COVER -

Section 4

a)	Please state the limit of indemnity insurance required under this insurance:
	$1,000,000 $2,000,000 $5,000,000 $10,000,000 $20,000,000

b)	Please state the excess required (in most cases an excess is compulsory)
	$2,500 $5,000 $7,500 $10,000 Other

c)	Extensions Required: (in most cases the available extensions to the cover will be automatic at no extra charge. However, each Underwriter considers the risk profile individually, therefore it is important you tell us the level of cover and extensions the organisation requires)

	Advance Payment of Defence Costs	Yes No
	Trade Practices and Related Legislation	Yes No
	Occupation Health and Safety	Yes No
	Breach of Contract	Yes No
	Libel and slander	Yes No
	Infringement of Copyright	Yes No
	Fraud and Dishonesty	Yes No
	Loss of Documents	Yes No
	Insured v Insured	Yes No
	Increased Aggregate Limit of Indemnity (Reinstatement)	Yes No
	Outside Directorship (Blanket and Run-off Cover)	Yes No
	Fidelity	Yes No
	Trusteeship (Blanket and Run-off Cover)	Yes No
I am unsure about the above Extensions. Please contact me to discuss.

DETAILS OF BOARD OF MANAGEMENT -

Section 5

PLEASE NOTE: If your application contains the most recent Annual Report of the Organisation and the Board of Management remains unchanged from that Annual Report then it is NOT necessary to complete this question. Simply tick the appropriate box below.

Details of the Board of Management of the Organisation are:

In the attached Annual Report Detailed below

Name of Board Member	Qualifications	Age	Date Appointed

FINANCIAL POSITION OF THE ORGANISATION -

Section 6

a)	Please attach (if possible) the last two (2) sets of Annual Reports and Financial Statements (including Audit Report) of the Organisation: (Microsoft Word or PDF only)	1. 2.

b)	Please attach (if possible) a copy of the Organisation's Memorandum of Association (Microsoft Word or PDF only)

c)	Has there been any changes in the financial position of the Organisation or is there any trend or event not reflected in the Annual Report and financial statements attached to this Proposal, that might materially affect the financial position in those statements?	Yes No

d)	Is any proposed Insured Person aware of facts or circumstances that might affect the ability of the Organisation to meet all its debts as and when they fall due?	Yes No
	If Yes, please supply details

CLAIMS HISTORY OF DIRECTORS, OFFICERS AND BOARD OR COMMITTEE MEMBERS -

Section 7

a)	Has there been, or is there now pending, any claims against any proposed Insured Person, in their capacity asa director, officer, secretary or committee member or employee of either the Organisation or any other company, organisation, association or trust?	Yes No
	If Yes, please supply details

b)	Do any circumstances exist that might give rise to a Claim against any proposed Insured Person?	Yes No
	If Yes, please supply details

CLAIMS HISTORY OF ORGANISATION -

Section 8

a)	Has there been, or is there now pending, any action, litigation or other proceedings against the Organisation, including any action, litigation or other proceeding brought under or pursuant to any Commonwealth, State, or Territory legislation?	Yes No
	If Yes, please supply details

b)	Has there been or is there now pending any investigation, examination, injury or other proceedings in relation to the affairs of the Organisation?	Yes No
	If Yes, please supply details

c)	What action has been taken to prevent a recurrence of the situation which gave rise to each loss or claim?

d)	Do any circumstances exist that might give rise to any event described under (a) or (b) above?	Yes No
	If Yes, please supply details

DISCLOSURES -

Section 9

Has any insurer, in respect of the risks to which this proposal relates, ever:

declined a proposal, refused renewal or terminated insurance?

Yes No

required an increased premium or imposed special conditions?

Yes No

declined an insurance claim by the proposer or reduced its liability to pay a claim in full (other than by application of an excess)?

Yes No

If Yes, to a), b) or c) please give details

After enquiry, are you as the person completing this proposal or any of the Board of Management / Committe of the Organisation aware of any circumstances that might affect an Insurer's consideration of this insurance?

Yes No

If Yes, please give details

It is agreed that if such facts, circumstances or situations exist, whether or not disclosed, any claim arising from them is excluded from proposed coverage.

DECLARATION

I/We the undersigned authorised Insured Persons, after enquiry declare as follows:

I am/We are authorised by each of the other Applicants to make this Proposal.

I/We have read and understood the Notice to the proposed Insured on the front of this Proposal.

I/We have read this Proposal and the accompanying documents and acknowledge the contents of same to be true and complete.

I/We understand that, up until a contract of insurance is entered into, I am/We are under a continuing obligation to immediately inform RGIB and the Underwriter of any change in the particulars or statements contained in this Proposal or in the accompanying documents.

Although the signing of this Proposal does not bind the Applicants to effect insurance, the Applicants acknowledge that the particulars and statements contained in this Proposal and in the accompanying documents shall be the basis of the contract should a Policy be issued; and further, the Applications acknowledge that the Proposal and the accompanying documents will be incorporated in the Policy.

Please examine your Duty of Disclosure

I agree to the above terms

THE ORGANISATION'S CONTACT DETAILS

Section 10

Address of where the Organisation is situated [Include Postcode and State]
Postal address if different from above [Include Postcode and State]
Telephone [Include Area Code]
Facsimile [Include Area Code]
Mobile
Email Address
Website Address
Do you have any other comments/requirements?

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