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Call +61 (2) 8599 8660 or 1300 172 321

Call +61 (2) 8599 8660 or 1300 172 321

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Association Liability Questionnaire for Clubs

Association Liability Questionnaire for Clubs

Club Name(Required)

Club Address(Required)

Street Address Address Line 2 City ZIP / Postal Code Country

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Has any claim or allegation ever been made or civil, criminal or regulatory proceedings brought against the company or any director, officer or employee (whether as directors, officers or employees of the company or any other company), in respect of the risks of the kind to which this proposal form relates?(Required)

No

Yes

Please provide full details(Required)

Has any director, officer or employee ever received a notice to attend an official investigation, examination, inquiry or other proceedings ordered or commissioned by an official body or institution, in respect of the risks of the kind to which this proposal form relates?(Required)

No

Yes

Please provide full details(Required)

During the last 5 years has the company suffered any loss as a result of any dishonest, fraudulent or criminal act of any employee or any third party (including theft of stock, goods, property or money) in respect of the risks of the kind to which this proposal form relates(Required)

No

Yes

Please provide full details(Required)

After enquiry, are any of the directors or officers of the company aware of any act, omission, conduct, allegation, fact, event, circumstance or matter which might reasonably be expected to:

Give rise to a claim or lead to civil or criminal proceedings against the company or any director, officer or employee?(Required)

No

Yes

Please provide full details(Required)

Result in the company or any director, officer or employee being required to attend an official investigation, examination, inquiry or other proceedings?(Required)

No

Yes

Please provide full details(Required)

Give rise to a fine or penalty or infringement notice (other than for traffic offences) imposed by any Federal, State, Territory or local government or regulatory authority.(Required)

No

Yes

Please provide full details(Required)

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