Application for Membership 2017

Transcription

1 Application for Membership 2017 ABN PO Box 6281 SILVERWATER BC NSW 1811 Phone Upon Payment this Document is a Tax Invoice Personal Details Prefix First Name Middle Name Surname Postal Address Mobile No Address Instructor Licence No Class (Please circle) Motorcycle Car MR HR HC MC I as an instructor primarily identify as (Please circle) Light Heavy Both Driving School Name Are you the proprietor of the Driving School? (Please circle) Yes No

2 For the Provision of Driver Training in REGISTERED Vehicles: Option One: Option Two: Option Three: $ $ $ Two Million Professional Indemnity Premium: $79.00 Ten Million Public Liability: Premium: $52.00 : $9.49 : : $35.60 Five Million Professional Indemnity Premium: $ Premium: $78.00 $14.10 $41.90 Ten Million Professional Indemnity Premium: $ Premium: $78.00 $15.70 $44.80 For the Provision of Driver Training in UNREGISTERED Vehicles: Option Four: Option Five: Option Six: $ $ $ Two Million Professional Indemnity Premium: $ $71.38 $ Five Million Professional Indemnity Premium: $ $91.18 $ Ten Million Professional Indemnity Premium: $ $ $ I select Coverage of Option *If you are unsure of which Option to select, please call the ADTA Office directly.

3 Payment Direct Bank Transfer: (Our preferred Method) Account Name: The Australian Driver Trainers Association NSW LTD Bank: Westpac // BSB: // Account Number: Reference: (Please use your Surname) Payment date and amount paid: / / $ Credit Card: Card Number: Expiry Date: CCV Number: Cardholders Name: Cardholder s Signature: Professional Indemnity & Public Liability Insurance Proposal Form 2017 Professional Indemnity Underwritten by CGU Insurance Limited//Public & Products Liability Underwritten by CGU Insurance Limited. Completion Instructions: Answer all questions. Blanks, dashes &/or n/a are not acceptable and will delay processing. Questions where underwriters already know the answers must also be answered. If there is insufficient room to complete a question, please attach a signed and dated sheet. Any documents attached to the proposal form are part of this proposal. Where appropriate, please circle yes or no to indicate your answer.

4 PART A: 1. Do you regularly use premises of another party who require their interests to be noted on the Public Liability Policy? (If yes please provide details). Yes/No 2. Qualifications: 3. Date Obtained: / / 4. Professional Services Provided: Car Driving Instruction: Registered Vehicle only % Unregistered Vehicle/Plant & Equip/Forklift Driving Instruction % Truck Vehicle Driving Instruction (5-10t) % Truck Vehicle Driving Instruction (>10t) % Motorbike Driving Instruction % Forklift & Plant/Machinery Instruction % Other driver/operator training (Please Specify) % 5. Do you engage any sub-contractors? Circle (If yes, how many, what are their activities and annual payments? Confirmation that own PL covers in place. Yes/No PART B: Claims: Please answer the following questions after enquiry within your organisation (this includes both Professional Indemnity and Broadform Liability insurance policies). 6. Have you ever been refused this type of insurance, or had similar insurance cancelled, or declined to renew, or had any special terms imposed? (If yes, please provide details). Yes/No

5 7. During the past 10 years has any Claim been made, or has negligence been alleged, against any entity or individual to be insured by this insurance (including any prior corporate entity and any of the present or former Principals), or have any circumstances which may give rise to a claim against any of these been notified to insurers? (If yes, please provide details). Yes/No 8. Are there any circumstances not already notified to insurers, which may give rise to a Claim against any entity or individual to be insured by this, insurance (including any prior corporate entity and any of the present or former Principals)? (If yes, please provide details.) Yes/No 9. Has any Principal or staff member ever been subject to disciplinary proceedings for professional misconduct? (If yes, please provide details.) Yes/No PART C: Declaration I/We hereby declare that: My/Our attention has been drawn to the Important Notice accompanying this Proposal form and further I/we have read these notices carefully and acknowledge my/our understanding of their content by my/our signature/s below. 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 Proposal form and the inception date of the insurance to which this Proposal relates I/we shall give immediately notice thereof. I/We authorize CGU Professional Risks, CGU Insurance Limited, to collect or disclose any personal information relating to this insurance to/from any other insurers or insurance reference service. Where I/we have provided 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 section in the Policy on The way we handle your personal information. I/We also confirm that the undersigned is/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 Proposal form, and I/we complete this Proposal form on their behalf. To be signed by the Chairman/President/Managing Partner/Managing Director/Principal of the association/partnership/company/practice/business. I agree to be bound by the code of conduct of the Australian Driver Trainers Association (NSW) Ltd. Name Date / / Signature