AGED CARE INSURANCE SERVICES - PROPOSAL FORM

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1 AGED CARE INSURANCE SERVICES - PROPOSAL FORM IMPORTANT FACTS RELATING TO THIS PROPOSAL FORM The Purpose of this Proposal Form is to set out all relevant information for your adviser to submit on your behalf to the insurer(s). Under the Insurance Contracts Act 1984, you are under a duty to make full disclosure in this Proposal Form as follows: Your Duty of Disclosure Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contract Act 1984 to disclose to the insurer every matter that you know or could reasonably be expected to know, is relevant to the insurer s decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of matters that diminish the risk to be undertaken by the insurer; that is of common knowledge; that your insurer knows, or in the ordinary course of their business, ought to know; as to which compliance with your duty is waived by the insurer. n-disclosure If you fail to comply with your duty of disclosure the insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the opportunity of voiding the contract from its beginning. There are other matters of which you should be aware in relation to the proposed professional indemnity insurance, as follows: Claims Made The proposed Professional Indemnity insurance policy is claims made and notified insurance i.e. it only covers claims made against you and notified to the insurers during the period of insurance. However, provided that you give the insurers notice of any circumstances that may give rise to a claim against you immediately you become aware of these facts and during the period of insurance, then this insurance will respond notwithstanding that no claim has actually been made against you during the period of insurance. Retroactive Liability There is provision in the proposed Professional Indemnity insurance policy for the operation of a retroactive date. Claims which subsequently arise from circumstances which occurred prior to the retroactive date are excluded. Liability Assumed Under Agreement The proposed Professional Indemnity insurance policy excluded liability arising out of any obligation assumed by way of warranty, guarantee or indemnity to the extent that such liability exceeds the liability which would have been incurred in the absence of such obligation. Utmost Good Faith A contract of insurance is based on the utmost good faith requiring the insurers and the insured to act towards each other with utmost good faith in respect of any matter arising in relation to the insurance. Privacy We are committed to protecting your privacy. To provide you with our services, which include negotiation and acquisition of insurance, we need to obtain certain information from you and pass it on to the third parties who are necessary to assist us in providing these services to you. These include insurers, accountants, lawyers and other advisers. We use the information you provide to advise about and assist with your insurance needs. We do not trade, rent or sell your information. For further information about our Privacy Policy, ask for a copy or visit our website -

2 All questions in this proposal form must be answered PROPOSED PERIOD OF INSURANCE Period of insurance: From To At 4pm GENERAL INFORMATION Name of organisation (Insured Entity) Service name (Trading Name) Postal address ABN Phone Number Fax Number Website Address Address All business addresses to be covered Please provide detailed business description, including all activities and services provided Details of any anticipated changes to the insured's occupation and/or activities for the ensuing 12 months? Activity Bed/Places Activity Number Nursing Home - High care CACP Programmes Hostel - Low care HACC Programmes Self Care / Retirement / ILU EACH Programmes Respite Care Programmes Other care activities - Attach full details Are you duly Licenced/Accredited in accordance with the law? When does your current Licence/Accreditation expire? Have you been advised or is there any reason to suspect that accreditation will not be granted in the future? If '', please provide details Date founded Years operated by present owners Has the business ever traded under a different name? If '', please provide details 2

3 Are you a registered t-for-profit (Charitable) organisation? Which Professional Associations are you a member of? -Include membership number Are your insurances subject to stamp duty exemption? If '', what is the exemption certificate date and number? Please attach a copy (NB should the name of the Insured Entity differ from the name on the stamp duty exemption certificate, you may not be able to obtain exemption) Please state your Gross Operational Income (including resident fees and Government subsidies) over the past 3 years Year20 $ Year20 $ Year20 $ Please indicate the approximate percentage of fees/turnover derived in each state or overseas and the number of staff in each state or overseas. Staff Fees/turnover NSW VIC QLD SA WA TAS NT ACT O/SEAS PROFESSIONAL INDEMNITY 1. Limit of Indemnity required $ 2. Please state number of employees engaged in the following classifications Registered Nurses Maintenance CACP Staff Enrolled Nurses Kitchen/Catering/Laundry HACC Staff Care Service Workers Clerical/Admin/Managers Hairdressers Podiatrist VHC (Veterans Home Care) EACH (Extended Aged Care at Home) Nurse Unit Manager Divisional Therapist Physiotherapist 3. Are any of the employees noted above engaged in more than one classification? Eg. staff involved in CACP/HACC programmes. If '', please provide details. 4. Will you ensure to the best of your ability that: (i) All medical practitioners who provide any services are at all times insured against professional liability through the MD.U. or similar? (ii) All statutory obligations, by-laws and regulations imposed by any Public Authority for the safety of persons or property are complied with? (iii) All nursing staff who provide any services are registered and fully qualified and that this information is recorded? If '', to any of the above, please provide details 3

4 5. Do you operate any clinics where you employ Doctors/Dentists etc.? If '', please provide details 6. (i) How many clients/ patients do you have on your database? (ii) And how many clients do you service per year? 7. In relation to the permanent staff (including directors, excluding admin) What is the total number of clients serviced for years. 8. Similarly with your casual staff how many clients do they service? 9. Is it the same clients they service weekly/ fortnightly or different clients each visit? 10. Are there any expected changes to the above over the next 12 months? If yes, please provide details 11. In relation to 'Respite - for carers', please provide details of the type of service offered: 12. Do you provide the following services and if so, please provide the number of patients per annum: SERVICE PATIENTS PER ANNUM Wound management Asthma & diabetes care Medication supervision Continence management Pain management Palliative Care Health assessment Meals preparation Meals delivery 4

5 COMBINED GENERAL LIABILITY 1. Limit of Indemnity required $ 2. Total employee numbers 3. Please state your annual payroll (including earnings of principals, directors, partners) over the last 3 years Year20 $ Year20 $ Year20 $ 4. (i) Do you engage or intend to engage the services of contractors and/or subcontractors? (ii) If '', do you strictly maintain a program to ensure control over contractors and/or sub-contractors? If '', please provide details 5. Please provide details of work performed and wages/fees paid to your contractors and/or subcontractors? (Labour only) 6. In terms of your contractual arrangement, do you insist being named either as a Principal or as a Joint Insured under Workers Compensation (where applicable) and Liability policies issued to your contractors and/or sub- contractors? 7. Do you hire or intend to hire from other company's additional labour not forming part of your permanent staff? If '', provide details of work performed by this component of your labour force. 8. Provide numbers of hired labour 9. Wages paid $ 10. In terms of your contractual arrangement for labour hire and contractors what are the details in regard to work safety, supervision and Workers Compensation issued? 11. Please provide details of any proposed fund raising activities? (eg fete, street stalls etc) 12. Please provide details if you hire-out any of your facilities? (eg halls, offices, pools etc) 5

6 INSURANCE HISTORY 1. Previous Claims/Loss History Has there been or is there now pending against the Insured Entity, any Insured Person, Director or Officer of the Insured Entity or any Subsidiary Companies or against any outside director for any claim in respect to Professional Indemnity, or Combined General Liability during the last ten years or has there been any acts of dishonesty? Date of incident Date of claim Amount claimed Amount paid Amount outstanding Class of claims and details including nature of the allegations and details of the claimant $ $ $ $ $ $ $ $ $ 2. Has there been any claims circumstances or losses which may lead to a claim being lodged against the Insured Entity and/or Insured Persons or losses suffered by the Insured Entity which were not covered by insurance as no policy was in force at the time? If '', please provide details 3. After investigation, is any of the Insured Persons, Directors, Officers or Employees aware of any facts, incidents, acts, events or Circumstances/complaints involving the molestation of any resident/patient? 4. After investigation, is any of the Insured Persons, Directors, Officers or Employees aware of any facts, incidents, acts, events or circumstances/complaints which might give rise to a claim being made against them, the Insured Entity or any of their Subsidiary Companies for any of the risks now proposed? Date Details including nature of the allegations and details of the claimant 6

7 5. Details of previous insurance held Class of Insurance Insurer Expiry date Limit of liability Excess Professional Indemnity $ Combined General Liability $ 6. Has an application for Professional Indemnity or Combined General made by you or your predecessors in business ever: (i) been declined? (ii) been cancelled? (iii) had special terms imposed? If '', please provide details DECLARATION I/we declare that the statements and particulars in this proposal are true and that I/we have not misstated or suppressed any material facts. I/we agree that this proposal form with any other information supplied on behalf of the business shall form the basis on any Contract of Insurance effected thereon. I/we undertake to inform the Insurer of any material alteration to these facts whether occurring before or after completion of the Contract of Insurance. We acknowledge receipt of the Important tices which were attached to this Proposal and that we have read and understood the contents of that tice. We further acknowledge that all/part of this proposal may not have been completed in our own hand and that we have carefully read this proposal and confirm that all the answers given are true and correct and should be taken as having been completed by ourselves. Signatures of Managing Director/President and one other executive officer. Signature: Position: Date: RETURN TO Address: Suite 1.01, Level 1, 27 Belgrave Street, MANLY NSW 2095 Fax: service@optimuminsurance.com.au 7