Management Liability Proposal Form

From

First name

Last name

Company name

Address

Phone Number

Website

Business Description

ABN

Year Business was established

Total number of Employees per state

Annual Revenue for THIS YEAR

Annual Revenue for LAST YEAR

Claim Information

Have you been declined or had any insurance policy cancelled

Have you suffered any loss whether covered by insurance or not

Are you aware of any facts that may give rise to any future claims

Do you hold an Australia Financial Services License

Are there any facts that might affect the ability to meet debts when they fall

Workplace Health and Safety

How many employees left employment in the last 6months

How may retrenchments or layoffs do you expect in the next year

Do you have written employment procedures in place

Do you maintain a list of authorised suppliers

Are dual authorities required for all deposits, withdrawals and transfers

Are counter signatures required on all cheques

Can the person who reconciles monthly statements also handle deposits

Are all Stocktakes reconciled by another employee

Please tick all that apply:

Do you have a safety management system in place

Do you have effective hazard & incident reporting procedures

Do you have procedures in place to identify WHS laws

Do you have a system that recognises contractors, volunteers & labour hire as workers

Do you have an audit program that ensures safety risks are up to date

None of the above

Tailored