GROUP PERSONAL ACCIDENT AND SICKNESS Insurance Proposal Form Catlin Australia Pty Ltd, trading as Brooklyn, an XL Group Platform (ABN 64 108 319 786) (AFSL 301617). Guidelines to help you complete this Proposal Form 1. Failure to disclose all material information that is likely to influence the acceptance of the risk or the terms applied could invalidate the insurance. If you are in any doubt as to whether any information is material, it should be disclosed. 2. Where the space provided is insufficient for your replies, please provide these separately and attach to this Proposal Form. 3. The terms proposer, whenever used in this proposal form shall mean the insured listed and all subsidiary companies of the insured for which coverage is proposed under this proposal. 4. The terms insured and subsidiaries have the same meaning in this proposal form as in the policy. Duty of Disclosure Before you enter into a contract of general insurance with an insurer, you have duty, under the Insurance Contracts 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 insurance, and if so, on what terms. You have this duty until we agree to insure you. Your duty of disclosure before you renew, extend, vary or reinstate an insurance contract is to tell us before the renewal, variation, extension, reinstatement or replacement is made, every matter known to you which: you know, or a reasonable person in the circumstances could be expected to know, is relevant to our decision whether to insure you and whether any special conditions need to apply to your policy Your duty however does not require disclosure of any matter: That diminishes the risk to be undertaken by the insurer; That is of common knowledge; That your insurer knows or, in the ordinary course of this business, ought to know; As to which compliance with your duty is waived by the insurer. If we request personal information about you and you do not provide it, we may not be able to provide you with the insurance product you request, manage or pay any claim under an insurance policy or provide you with the full range of services we offer. Privacy Brooklyn is bound by the Privacy Act 1988 and requires us to inform you that: We collect, disclose and handle personal and/or sensitive (e.g. health) information, about you ( personal details ) for the purposes of; identifying you when you do business with us; protecting your personal information from unauthorised access; establishing your requirements and providing the appropriate product or service including evaluating your application for insurance and any request for amendment to any insurance provided; setting up, issuing, administering and managing the insurance following acceptance of an application; assessing and investigating, and if covered, manage claims and improving our financial products and services, including training and developing our staff and representatives. We may disclose your details, including your sensitive information, to intermediaries including your agent, adviser, a broker, a representative acting on your behalf, other Australian Financial Services Licensee or our authorised representatives and our agents, other insurers and reinsurers, our service providers, our business partners, health practitioners, your employer, parties affected by claims, government bodies, regulators, law enforcement bodies and as required by law, within Australia and overseas. Our Privacy Policy contains information about how you can access the information we hold about you, ask us to correct it, or make a privacy related complaint. You can obtain a copy from our Privacy Officer by telephone (+61 (0)2 8270 1790), or by visiting our website (www.brooklynunderwriting.com.au). By providing us with your personal information, you consent to its collection and use as outlined above and in our Privacy Policy. GROUP PERSONAL ACCIDENT AND SICKNESS Insurance Proposal Form Page 1
1. DETAILS OF THE PROPOSER Full Name of Insured: ABN: Business address: State: Post code: Nature of business: Occupation of Insured Persons: Nature of work duties: 2. PERIOD OF INSURANCE From (Inception): To (Expiry): 3. NUMBER OF PERSONS TO BE COVERED ACT NSW NT QLD SA TAS VIC WA Employees Directors/Board members Other For Other, please provide details of persons to be Insured: Is this cover required as part of an Enterprise Bargaining Agreement (EBA)? GROUP PERSONAL ACCIDENT AND SICKNESS Insurance Proposal Form Page 2
4. DETAILS OF PERSONS TO BE COVERED Please detail the number of Insured persons into the following aged brackets. Age Up to 30 31-40 41-50 51-60 61-75 Employees Directors / Board members Other Alternatively please provide an employee listing in excel spreadsheet along with this proposal form. Do any of the persons to be covered as a pilot or passenger in any aircraft other than scheduled airlines? Annual Wageroll of Insured Persons: $ Do any of the persons to be covered have any cause to consider themselves not presently in good health? Do any of the Persons to be covered require cover for any hazardous pastimes activities? 5. SCOPE OF COVER - Please select when you would like to be covered: *Please select one option 24 hours, 365 Days During working hours only including commute to and from work During working hours only Outside working hours only Whilst attending board meetings and other scheduled events on behalf of the insured GROUP PERSONAL ACCIDENT AND SICKNESS Insurance Proposal Form Page 3
6. BENEFITS REQUESTED - Please advise what you would like to be covered for: Part A - Lump Sum Benefits (Events 1-19) $ Part B - Weekly Injury (Events 20 and 21) $ Part D - Weekly Sickness (Event 27 and 28) $ Waiting Period (Days) Benefit Period (Weeks) Part F - Injury Resulting in Fractured Bones (Events 33-41) Part G - Injury Resulting in Loss or Damage to Teeth (Events 42 and 43) Aggregate limit of Liability $ n-scheduled limit of Liability $ 7. PREVIOUS INSURANCE HISTORY Does the Proposer currently have, or has the Proposer ever been insured for the risk for which cover is required? (If YES, please provide details of benefits and the name of the insurer) Has the Insured/Insured Person(s) ever made a claim for Accident and/or Sickness? (If YES, please provide of Date of Loss, Nature of Loss, Amount etc.) Has any insurer, in respect of the risks to which this proposal relates, ever: a) Declined the Insured s application? b) Cancelled or refused renewal of a Policy? c) Required an increased premium or imposed special terms? (If YES, please provide details) GROUP PERSONAL ACCIDENT AND SICKNESS Insurance Proposal Form Page 4
8. DECLARATION I/We the undersigned duly authorised person(s) declare that: i. The above statement are correct, true and complete; and ii. information material to this Proposal Form has been withheld; and iii. 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 iv. I/We undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance; and v. 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. Signature of Insured or Authorised Representative: Date: Print Name: GROUP PERSONAL ACCIDENT AND SICKNESS Insurance Proposal Form Page 5