zurich aged care, combined liabilities - home au · aged care proposal – page 3 of 9 general...

Zurich Australian Insurance Limited ABN 13 000 296 640, AFS Licence No. 232507. 5 Blue Street North Sydney NSW 2060. Aged Care Proposal – of 9

Zurich Aged Care, Combined LiabilitiesProposal form

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Important information – Please read the following before completing this proposal.

• Professional Indemnity • Directors & Officers Liability • Employment Practices Liability • Combined General Liability • Fidelity Guarantee

Completing the Proposal form1. This application must be completed in full including all required attachments.

2. If more space is needed to answer a question, please attach a separate sheet with details.

3. The terms Proposer, whenever used in this Proposal form shall mean the policyholder listed and all subsidiary companies of the policyholder for which coverage is proposed under this Proposal.

4. The terms policyholder and subsidiaries have the same meaning in this Proposal form as in the policy.

Duty of DisclosureBefore you enter into a contract of general insurance with us, you have a duty under the Insurance Contracts Act 1984 (Cth) to disclose to us every matter you know, or could reasonably be expected to know, is relevant to our decision whether to insure you and, if so, on what terms. This applies to all persons to be covered under this contract of insurance.

You have the same duty to disclose those matters to us before you renew, extend, vary or reinstate a contract of general insurance. Your duty however, does not require disclosure of a matter that:

• diminishes the risk to be insured;

• is of common knowledge;

• we know or in the ordinary course of our business we ought to know;

• we indicate to you that we do not want to know.

PrivacyZurich is bound by the Privacy Act 1988 (Cth). Before providing us with any Personal or Sensitive Information (‘Information’), you should know that:

We collect, use, process and store Personal Information and, in some cases, Sensitive Information about you in order to comply with our legal obligations, assess your application and, if your application is successful, to administer the products or services provided to you, to enhance customer service and/or product options or manage a claim (‘purposes’).

If you do not agree to provide us with the Information, we may not be able to process your application, administer your policy or assess your claims.

By providing us or your intermediary with your Information, you consent to our use of this Information which includes us disclosing your Information where relevant for the purposes, to your intermediary, affiliates of the Zurich Insurance Group Ltd, other insurers and reinsurers, our service providers, our business partners or as required by law within Australia or overseas.

Zurich may obtain Information from government offices and third parties to assess a claim in the event of loss or damage.

For further information about Zurich’s Privacy Policy, a list of service providers and business partners that we may disclose your Information to, a list of countries in which recipients of your Information are likely to be located, details of how you can access or correct the Information we hold about you or make a complaint, please refer to the Privacy link on our homepage – www.zurich.com.au, contact us by telephone on 132 687 or email us at [email protected]

Non-disclosure or MisrepresentationIf you make a misrepresentation to us, or if you do not comply with your duty of disclosure and we issue your policy with terms and conditions that are different to the terms and conditions that would have been issued had there not been any misrepresentation, or your duty of disclosure had been complied with, then:

• we may reduce the cover provided so that we are placed in the same position as we would have been in, had there not been any misrepresentation and your duty of disclosure had been complied with; and

• we may also cancel your policy; or

• we may treat your policy as if it never existed if the misrepresentation or your non-compliance with your duty of disclosure was fraudulent.

Statutory Notice – Section 40 Insurance Contracts Act 1984 (Cth)This notice is provided in connection with but does not form part of the policy.

This policy is a ‘Claims Made’ liability insurance policy, apart from Commercial Crime. It only provides cover if:

• A claim is made against an insured, by some other person, during the period when the policy is in force; and

• The claim arises out of circumstances committed, attempted or alleged to have been committed or attempted after the date of continuous cover stipulated in the schedule.

Section 40(3) of the Insurance Contracts Act 1984 (Cth) applies to this type of policy. That sub-section provides that if an insured becomes aware, during the period of insurance, of any fact or circumstance which might give rise to a claim against them by some other person, then provided that the insured notifies Zurich of the matter before this policy expires, Zurich may not refuse to indemnify merely because a claim resulting from the matter is not made against the insured while the policy is in force.

If an insured, inadvertently or otherwise, does not notify the relevant facts or circumstances to Zurich before the expiry of the policy, the insured will not have the benefit of section 40(3) and Zurich may refuse to pay any subsequent claim, notwithstanding that the events giving rise to it or the circumstances alleged in it may have taken place during the period of insurance.

If a claim is actually made against the insured by some other person during the period of insurance but is not notified to Zurich until after the policy has expired, Zurich may refuse to pay or may reduce its payment under the policy if it has suffered any financial prejudice as a result of the late notification.

Aged Care Proposal – of 9

Reasonable care(a) You must exercise reasonable care that only competent employees are employed and take reasonable measures to maintain all premises,

fittings and plant in sound condition.

(b) The insured persons shall take all reasonable care and precautions:

(i) to prevent personal injury, property damage or advertising liability losses;

(ii) to prevent the manufacture, sale or supply of defective products;

(iii) to comply with all statutory obligations, by-laws or regulations imposed by any public authority for the safety of persons or property.

(c) You shall at your own expense withdraw, inspect, repair, replace, trace, recall or modify any of the products containing any defect or deficiency of which you have knowledge or have reason to suspect.

Contracts by the insured affecting rights to subrogationWhere another person or company would be liable to compensate the Insured or hold the Insured harmless for part or all of any Loss or damage otherwise covered by the policy, but the Insured has agreed with that person or company either before or after the inception of the policy that recovery of any Loss or damage from that person or company would not be sought, the Insured will not be covered under the policy for any such Loss or damage.

Policy detailsFor full details of Zurich Aged Care, Combined Liabilities Insurance please refer to the Policy document. This is available from the local Zurich Office or your broker or intermediary.

General information

Name of organisation (Insured Entity) ABN

Service name

Postal address State Postcode

Contact details: Business ( ) Fax ( )

All business addresses to be covered

State Postcode

State Postcode

State Postcode

Business description and activities

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 Aged Care Act 1997? Yes No Please provide a copy of your most recent accreditation certificate / report

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? Yes No

If 'Yes', please provide details

Date founded / / Years operated by present owners

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Proposed period of insurance

Period of insurance: From / / To / / at 4pm

1


General information (continued)

Has the business ever traded under a different name? Yes No If 'Yes', please provide details

Are you a registered Not-For-Profit (Charitable) organisation? Yes No

Which Professional Associations are you a member of? – Include membership number

Are your insurances subject to stamp duty exemption? Yes No

If 'Yes', what is the exemption certificate date and number? / / 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

Year 20_____ $ Year 20_____ $ Year 20_____ $

Do you have any operations outside of Australia? Yes No If ‘Yes’, please provide details

Please indicate the approximate percentage of fees/turnover derived in each state or overseas and the number of staff in each state or overseas

NSW VIC QLD SA WA TAS NT ACT O/S

Staff

Fees/turnover % % % % % % % % %

2

Professional indemnity

Limit of Indemnity required $

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 Hairdressers VHC (Veterans Home Care)

Clerical/Admin/Managers Podiatrist EACH (Extended Aged Care at Home)

Nurse Unit Manager Divisional Therapist Physiotherapist

Are any of the employees noted above engaged in more than one classification? Yes No

Eg. staff involved in CACP/HACC programmes. If 'Yes', please provide details

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 M.D.U. or similar? Yes No

(ii) All statutory obligations, by-laws and regulations imposed by any Public Authority for the safety of persons or property are complied with? Yes No

(iii) All nursing staff who provide any services are registered and fully qualified and that this information is recorded? Yes No

If 'No', to any of the above, please provide details

(iv) Do you operate any clinics where you employ medical practitioners? Yes No


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Fidelity Guarantee


(i) Are bank accounts reconciled by someone also authorised to do withdrawals or deposits? Yes No

If 'Yes', please advise how often this occurs

(ii) Is a counter signature required on all cheques? Yes No

(iii) Who performs the internal and external audits and how often are these performed?

(iv) Within the last 18 months has the business received any auditors' letters regarding internal control weaknesses? Yes No


(v) Will you ensure to the best of your ability that only competent employees are employed? Yes No

Please advise total employee numbers by category

Class 1Executives not referred to in Classes 2 and 3

Class 2Employees engaged in handling money/negotiable instruments. stock and store supervisors

Class 3Employees engaged in services in resident homes

Class 4(a)Work experience students and temporary staff

Class 4(b)All other employees not included in Classes 1, 2, 3 or 4(a)

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Directors & Officers Liability


If the Insured Entity is a subsidiary of another entity, please advise the name of the ultimate holding company

Does any shareholder own directly or beneficially 10% or more of the share capital or voting rights of the Insured Entity or its subsidiaries? Yes No

If 'Yes', please provide details and whether there is board representation

Name of shareholder Percentage held Board representation

Yes No

Yes No

Yes No

Yes No

Yes No

Does the Insured Entity or any of its subsidiaries conduct business in the United States of America or Canada or their protectorates or territories? Yes No

Has the Insured Entity or any Subsidiary Company;

(i) publicly announced that it is considering any acquisitions, tender offers or mergers at the present time? Yes No

(ii) made any acquisition, disposal, merger or takeover in the last 3 years? Yes No

(iii) been the subject of any attempted takeover bid/offer in the last 3 years or is aware of any current Proposals relating to its takeover? Yes No

(iv) operated or is operating in a joint venture? Yes No

If you answered 'Yes', to any of the above questions, please provide details

5


Directors & Officers Liability (continued)

Has there been any change, adverse or otherwise, in the financial position of the Insured Entity or any Subsidiary Company, or any events which have occurred which are not detailed in the Annual Report/s submitted, which might materially affect the risk? Yes No


Has the Insured Entity issued any prospectus in the last 3 years or publicly disclosed its intention to make any new public offering of securities within the next year? Yes No

If 'Yes', please provide details. If prospectus liability cover is required, please provide a copy of the prospectus document for underwriting consideration

Does the Insured Entity or any Subsidiary act as manager of any funds or properties for or on behalf of a third party? Yes No


Has any Director or Executive Officer of the Insured Entity ever been declared bankrupt or been a Director or Executive Officer of an organisation placed in receivership, liquidation or provisional liquidation? Yes No


Has there been or is there now pending any prosecution of the Insured Entity or its Subsidiaries under the Corporations Act, Competition and Consumer Act or any other statute? Yes No


5

Employment Practices Liability (optional extension)


Employees – How many employees does the Insured Entity have in the following categories?

Officers Employees

Officers mean those individuals concerned with the management of the Insured Entity, including all Directors. Employees mean all those not included as Officers

State the number of employees and workers of the Insured Entity for the past 3 years

20________ 20________ 20________

Full time employees

Part time employees

Temporary workers

Contract workers

For each of the past three years, what has been the annual percentage turnover rate of employees.

Turnover rate should be calculated as follows: number of separations during the month divided by average number of employees on payroll during the month x 12

Year 20______ % Year 20______ % Year 20______ %

Indicate below the salary range of employees/officers of the Insured Entity

Number of employees Percent of total

Employees receiving $50,000 or less per year %

Employees receiving over $50,000 to $100,000 per year %

Employees receiving over $100,000 per year %

6


Employment Practices Liability (continued)

Human Resources – Does the Insured Entity have a Human Resources (HR) or personnel department? Yes No

If 'Yes', how many employees are in this department?

If 'No', who performs HR functions for the Insured Entity?

How are Human Resource functions handled in the branch offices? What training is given?

Please attach answer on a separate sheet of paper, if more space is needed

Total number of employer initiated terminations in the last 3 years

How many officers and employees have resigned, been terminated (with or without cause) or have taken early retirement within the last 24 months?

Officers Employees

Does the Insured Entity have a written Human Resources manual or equivalent written management guidelines? Yes No

Does the Insured Entity have a formal out-placement program which assists terminated or retrenched employees in finding other employment? Yes No

Please tick 4 box if the manual/guidelines include a policy or procedure with respect to the following events:

Compliance with statutes Legally prohibited discrimination

Confidential treatment of medical examinations Redundancies, termination of employment and early retirement

Employee appraisals/reviews Sexual harassment

Employee disciplinary actions Written application for employment

Employee out-placement services

Corporate History – Have there been any facility, or office closings, consolidations or retrenchments within the last 24 months? Yes No

If 'Yes', please provide details, including how many employees have been affected

Does the Insured Entity anticipate any facility, or office closings, consolidations or retrenchments within the next 24 months? Yes No

If 'Yes', please provide details, including how many employees will be affected

(i) Has the Insured Entity acquired or sold any companies in the past five years? Yes No

(ii) Did the purchase or sale include assumption or transfer of liabilities? Yes No

(iii) With respect to acquired companies, were any employees or officers terminated, or does the Insured Entity plan in the next eighteen months to terminate any employees or officers? Yes No

(iv) Have there been any inquiries, investigations, grievance filings or other administrative hearings previously filed with or currently before any local or governmental agency governing employer responsibility to employees? Yes No

If 'Yes', to any of the above questions, please provide details

6


Combined General Liability


Please state your estimated turnover for the current financial year $

Please state your actual turnover for the past 3 financial years

FY end......../......../............ $ FY end......../......../............ $ FY end......../......../............ $

Total employee numbers

Please state your annual payroll (including earnings of principals, directors, partners) over the last 3 years

Year 20_______ $ Year 20_______ $ Year 20_______ $

Do you engage or intend to engage the services of contractors and/or sub-contractors? Yes No

If 'Yes', do you strictly maintain a program to ensure control over contractors and/or sub-contractors? Yes No


Please provide details of work performed and wages/fees paid to your contractors and/or sub-contractors? (Labour only)

In terms of your contractual arrangements, do you insist on 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? Yes No

Do you assume any liability or hold any party harmless under contract? Yes No


Do you hire or intend to hire from other companies additional labour not forming part of your permanent staff? Yes No

If 'Yes', provide details of work performed by this component of your labour force

Provide numbers of hired labour Wages paid $

In terms of your contractual arrangements for labour hire and contractors, what are the details in regard to work safety, supervision and Workers Compensation issued?

Does your storage, use and disposal of all toxic substances comply with all statutory regulations and by-laws? Yes No


Please provide details of any proposed fund raising activities? (eg fete, street stalls etc)

Please provide details if you hire-out any of your facilities? (eg halls, offices, pools etc)

7


Insurance historyPrevious Claims/Loss HistoryHas there been during the last 10 years or is there now pending against the Insured Entity, any Insured Person, Director or Officer of the Insured Entity or any Subsidiary Companies or any outside director any claim in respect of Professional Indemnity, Directors & Officers Liability, Employment Practices Liability, Management Liability, Statutory Liability, Internet Liability or Combined General Liability? Yes No


Date of incident

Date of claim

Amount claimed Amount paid Amountoutstanding

Class of claims and details including nature of the allegations and details of the claimant

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

$ $ $

Have there been any acts of fraud or dishonesty or incidents in respect of Fidelity Guarantee or Commercial Crime during the last 5 years? Yes No

If ‘Yes’, please provide details

Have 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? Yes No


After investigation, are 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? Yes No


After investigation, are 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? Yes No

Date Details including nature of the allegations and details of the claimant

8


Insurance history (continued)

Details of previous insurance held

Insurer Expiry date Limit of Liability Excess

Professional Indemnity $

Directors & Officers Liability $

Employment Practices Liability $

Fidelity Guarantee/Commercial Crime $

Management Liability $

Statutory Liability $

Internet Liability $

Combined General Liability $

With reference to the types of insurance listed in the table above, has any insurance company:

(a) declined to accept a Proposal? Yes No

(b) cancelled a policy, contrary to the proposer’s wishes? Yes No

(c) declined to renew a policy, contrary to the proposer’s wishes? Yes No


8

Signature Position Date

✗ / /

✗ / /

Print FormSave File

DeclarationI/we declare that the statements and particulars in this Proposal are true and that I/we have not mis-stated or suppressed any material facts. I/we agree that this Proposal together 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 Notices which were attached to this Proposal and that we have read and understood the contents of those Notices. 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.

9

N.B. IF DIRECTORS AND OFFICERS LIABILITY INSURANCE IS REQUIRED, PLEASE ENCLOSE A FULL COPY OF YOUR LATEST AUDITED ANNUAL REPORT AND STATUTORY DECLARATION IF APPLICABLE.

zurich aged care, combined liabilities - home au · aged care proposal – page 3 of 9 general...

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