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Fidelity Bonds Scheme Form

Fidelity Bonds Questionnaire 2024

YOUR DETAILS

Full Name
Full Name
First
Last
Structure
11 Digits
GST Registered
Physical Address
Physical Address
City
State/Province
Zip/Postal
Same as your Postal Address
Postal Address
Postal Address
City
State/Province
Zip/Postal
Do you hold an Agents Licence
Do you belong to any Association

TURNOVER

Turnover is the total gross sales/invoices generated by the business, less the GST, but including all payments made to sub-contractors. Turnover is not the actual or estimated profit or pre-tax profit of the business.

STAFF

YOUR OCCUPATION

BUSINESS ACTIVITIES OR SERVICES PROVIDED

Activities or Services
You can select more than one option

IMPORTANT INFORMATION RELATING TO THE ENTITY TO BE COVERED

Have any claims or complaints ever been made against you or the business
Are you aware of any circumstance, which may result in a Fidelity claim against you or the business
Have you or the business ever been declared bankrupt or placed into receivership or liquidation
Have you or the business ever been charged with or convicted of a criminal offence
Have you or the business ever had a Fidelity Bond declined or cancelled

YOUR CURRENT BOND DETAILS

Do you have a current Bond
Do you want to upload your current Bond

Maximum file size: 5MB

Fidelity Bond Required - WESTERN AUSTRALIA
Fidelity Bond Required - NORTHERN TERRITORY

DUTY OF DISCLOSURE

Before you enter into a Contract of general insurance with an Insurer, you have a duty under the Insurance Contracts Act 1984 to disclose to the Insurer every matter that you know, or could reasonably expect to know, is relevant to the Insurer's decision whether to accept the risk of Insurance and if so, on what terms. You have the same duty to disclose those matters to the Insurer before you renew, extend, vary or reinstate a Contract of general insurance. Your duty however does not require disclosure of matter.

  • that diminishes the risk to be undertaken by the Insurer
  • that is common knowledge
  • that your Insurer knows or, in the ordinary course of business, ought to know
  • as to which the compliance with your duty is waived by the insurer

Non-Disclosure

If you fail to comply with your duty of disclosure, the Insurer may be entitled to reduce the liability under the

Contract in respect of a claim or may cancel the Contract. If your non-disclosure is fraudulent, the Insurer may also have the option of avoiding the Contract from its beginning.

Answer all questions correctly to comply with your duty of disclosure

Do you understand your Duty of Disclosure

DECLARATION

I/We hereby declare that:

My/Our attention has been drawn to the Important Notice of 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 the 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 authorise White Insurance Brokers and White Group (VIC) Pty Ltd, to collect or disclose any personal information relating to this insurance to/from any insurers or insurance or Credit reference service. Where I/we have provided information about another individual I/we declare that the individual has been or will be made aware of that fact.

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 bond which may be issued pursuant to this Proposal form, and I/we complete this Proposal form on their behalf.

Your Name
Your Name
First
Last