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 Brokers National 

Brokers National Can Protect You As Directors Of Corporations From Making Unsound Decisions That May Result In Legal Action Against You By Third Parties                                                The Insurer Will Require Financials Of The Corporation & Summary Resume Of Each Director's Qualifications & Experience                                      Simply Complete The Answers To All Questions Below

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On-Line Directors and Officers Indemnity Insurance Quote


Thank you for considering our on-line directors & office bearers liability insurance quote service. Brokers National has accounts with most insurers and underwriting agencies. We aim to find you the best directors & officers indemnity insurance deal possible.

Please fill in the following form - answering all questions, then either:

1. Click on "Email to Brokers National" at the bottom of this form.  OR                               

2. Highlight this form to "Print It" and then "Fax It" to our office on 03 9791 6633.


 Use the Mouse or the Tab key to move to the next field. We will respond with quotes as soon as they have been received from our insurers.


Limit of Liability Required:

   
State the Limit of Indemnity required: $
State the excess you wish to pay towards a claim: $
Are you currently insured?   Yes    No 
If Yes, please give full details of directors & office bearers insurer below:    
Expiry Date Insurance Company   Indemnity Limit   Excess   Premium
$ $ $
Please give a clear description of the company's activities:  
Legal status of the Corporation:   Listed    Private    Non-Profit
Unlisted    Co-op/Mutual  
Other, please specify
Date the Corporation commenced business (as referred above)  
Is the Corporation a subsidiary of another entity ?   Yes    No 
If Yes, please provide details:  
Is there any shareholder holding, directly or beneficially, 10% or more of the ordinary share capital of the Corporation ?   Yes    No 
If Yes, please provide the name of the share holder and the percentage held:  
Director/Executive Officer Details
   
Are any of the directors currently members of any professional association (e.g. Australian Institute of Company Directors)   Yes    No 
If Yes, please provide details:  
Does the Corporation have an audit or compliance committee ?   Yes    No 
Has any director / executive of the Corporation been declared bankrupt?   Yes    No 
If Yes, please provide details:  
Has any director / executive of the Corporation been a director of an organisation placed in receivership, liquidation or provisional liquidation?   Yes    No 
If Yes, please provide details:  
Has there ever been any acquisition or disposal, merger or takeover undertaken by the Corporation or any subsidiaries in the last 24 months?   Yes    No 
If Yes, please provide details:  
Corporation Insurance Details
   
Has the Company or subsidiary ever been refused insurance, policy cancelled, or declined to renew, or any special terms imposed ?   Yes    No 
If Yes, please provide details  
 Corporation's Financial Information  
 
                      This Year
                               Last Year
Current Assets
Cash
Debtors
Other
 
 Total Current Assets  
Non-current Assets
Total Assets
Current Liabilities
Creditors
Borrowings
Other
 
 Total Current Liabilities  
Non Current Borrowings
Other non-current Liabilities
Sales
Profit
     
Are the accounts of the Company consolidated?
Yes    No 
Are the accounts audited ?
Yes    No 
Have the audited accounts been qualified ?
Yes    No 
If Yes, please provide details
Have the accounts been certified by the directors as a true and fair view of the company's financial position ?
Yes    No 
Is there any other information of a material nature not disclosed in the financials that could effect the financial position, capital structure or operation of the Company?
Yes    No 
If Yes, please provide details
Are there any contingent liabilities or events subsequent to the balance date ?
Yes    No 
     


Claims:

   
Have any claims been made, or pending against any person proposing for this insurance?   Yes    No 
Is any person proposed for insurance aware of any circumstances or incident which you have reason might result in grounds for any future claim within the scope of the proposed insurance?   Yes    No 
Has there been, or is there pending, any prosecution of the Corporation of its subsidiaries or any official investigation, examination or enquiry of the Corporation or its subsidiaries under the Corporations Act, Trade Practices Act, Occupational Health & Safety Act or any other statute?   Yes    No 
If Yes to any of the above questions please include details:  


Optional Extensions:

    
Outside Directorships - This extension provides indemnity to Directors and Officers who currently represent the Company interest in any nominated non-profit organisation:.    
Please provide a list of nominated non-profit organisations to be covered by this extension and any claims lodged or pending:  
Any policy extensions required?    
Current Outside Directorships other than Non-Profit Organisations:   Yes    No 
Prospectus Liability Cover:   Yes    No 
Joint Venture Cover:   Yes    No 
Pre-Aquisition Liability:   Yes    No 
USA & Canada Jurisdiction:   Yes    No 
Any other notes you wish to include:
 

Contacting you about your quote: 
Please make sure you leave a contact phone number and the best time to call you.

Your Name:
Company Name:
Your Phone Number & Area Code:
Best Time(s) To Call:
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