RTO Professional Indemnity & Liability Insurance

Insured Details

Insured Name (Legal Entity Name)*

Telephone*

Contact Name*

Email*

ABN*

Website

Number of Directors/Principals*

Number of Employees*

Total Number of Staff

Date of Establishment*

Address*

Street Address City State Postcode Country

Coverage Start Date*

What date do you require coverage by?

Business Activity

Please provide a thorough description of your exact business activities:

Business Description*

Please provide an approximate percentage of income based on the training or services you provide (must add up to 100% to proceed):

Accredited Training

Non-Accredited Training

Registered Training / Organisation Auditing

Education Consulting Services

Training Consulting Services

Learner Driver Training

Other Professional Services

Additional Coverage Details*

Please provide details of the work undertaken under Other Professional Services including relevant experience and qualifications to carry out these services:

TOTAL (must equal 100% to proceed)*

General Insurance Information

Insurance History*

Has any insurer, in respect of the risks to which this proposal relates, ever declined a proposal, refused renewal, or terminate any insurance and/or declined an insurance claim by the proposer of reduced its liability to pay an insurance claim in full (besides application of an excess?

Yes

No

Known Details*

Please provide details:

Bankruptcy / Insolvency*

Have you ever, either alone or jointly with others been declared bankrupt or subject to any form of insolvency administration (e.g., liquidation or receivership)?

Yes

No

Known Details*

Please provide details:

Declaration

I/We the undersigned duly authorised person(s) declare that:

I am / we are authorised by each of the Proposers to sign this Proposal Form; and
The above statements are correct, true and complete; and
No information material to this Proposal Form has been withheld; and
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
I / we undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance; and
I / we undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance; and
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.

Full Name of Applicant/s*

First Name

Last Name

Company*

Signature/s*

Date*

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RTO Professional Indemnity & Liability Insurance

Insured Details

Business Activity

Training Specifications

Coverage Selection & Additional Information

Claims Information

General Insurance Information

Declaration