Professional Indemnity Page 6
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7Retroactive Cover
20. Do you require retroactive cover which may be subject to additional premium?
Retroactive cover extends cover under the Policy to liability arising from work carried out prior to the inception of the Policy to which this
Proposal relates. There will be no cover for Claims arising from a Known Circumstance as at Policy inception.
D D
/
M M
/
Y Y
No
Yes
Please state date from which retroactive cover is required:
Optional Extensions – Employment Practices Liability and/or Fidelity
21. a. Do you require Employment Practices Liability cover, subject to additional premium?
No
Yes
A further addendum will need to be completed. Please request a copy of this form.
b. Do you require Fidelity cover, subject to additional premium?
No
Yes
A further addendum will need to be completed. Please request a copy of this form.
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
th 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 agree that, by submitting this form, the personal information I/we provide to CGU Insurance Limited in this form or otherwise may be collected,
held, used and disclosed in the manner set out in the CGU Privacy Policy found at , including for processing this application
and providing me/us with cover.
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.
Signature
Date
D D
/
M M
/
Y Y
Signature
Date
D D
/
M M
/
Y Y
It is important the signatory/signatories to the Declaration is/are fully aware of the scope of this insurance so that all questions can be answered.
If in doubt, please contact your insurance broker since non-disclosure may affect an Insured’s right of recovery under the policy or lead to it being avoided.
Insurance Broker’s Details
Broker Name
Account Number
Address
Postcode
Phone
Fax
Contact Name
Enquiries
13 24 81
Mailing address
Claims
13 24 80
GPO Box 9902 in your capital city
Sydney
Melbourne
Brisbane
Perth
Adelaide
388 George St
181 William St
189 Grey St
46 Colin St
80 Flinders St
Sydney
Melbourne
South Bank
West Perth
Adelaide
NSW 2000
VIC 3000
QLD 4101
WA 6005
SA 5000
CGU Professional Risks
.AU/PROFESSIONAL RISKS
CGU Insurance Limited
ABN 27 004 478 371
P0034 REV15 4/15 (CGU MISC PI 05-15)
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