MARSH GENERAL All questions are to be answered If insufficient

MARSH GENERAL All questions are to be answered. If insufficient space, please attach additional information Insuredis: PublicCompany D Incorporated Association D Incorporated Statute D by Other I I Are you Stamp Duty exempt? If yes provide exemption number I I Telephone Postal Address I Fax 1 Email Telephone I F~J LIABILITY Limit of Indemnity required Public Liability I $10,000,000 (anyone occurrence) I Products Liability I $10,000,000 I Deductible I $1,000 ) I (In the aggregate per period of Insurance) Policy Period Requested: FromI I I I ~ Marsh McLennan & Companies page1 of5 ~ MARSH l~~~~r Organisation 1. Please state the full details of your Group Activities. Please attach brochures, latest annual reports and other pertinent material that provides insight to your activities. 2. a) What is the primary Activity of your Group (what is your main funded activity)? b) State any other activities your organisation carries out, ego deliver meals, transport clients, respite care, lawn mowing, etc 3. Number of years organisation/group has been established? I I 5. Does your organisation enter into any contracts? If "Yes", does your organisation assume liability for any third party in these contacts? Copies attached D NoD If "Yes", please provide copies of all contracts. Please note: Cover will not be granted unless specified on the schedule 6. Does your organisation engage in any other business operations under the name of the insured as it will appear on this policy? If "Yes", please explain NoD 7. Has your organisation ever had any type of insurance: Cancelled D If so, please explain Non-renewed D 8. Have you had any claims made against you (whether insured or not) in the last 5 years? If "Yes", please provide details ~ YesD NoD ~ Marsh McLennan & Companies page 2 of5 ~ 1. a) Does your Organisation participate in or organise any Fundraising activities, stalls, fetes etc? Yes D b) If so, please provide details of the activity, number of events, and estimated number of people to attend. Please provide additional page if necessary. 2. Description of EvenVOperation/Business 3. What is your organisation's past experience at running this type of event? 1. Please provide details of your organisations' gross eamings/tumover/gate takings for last financial year (all sources) Government Funding Fund Raising Activities Donations not included in above Other (Please provide details) TOTAL 2. Please provide this financial Government Funding year's expected gross earnings/turnover/gate takings (all sources) $ $ $ $ $ Fund Raising Activities Donations not included in above Other (Please provide details) TOTAL 3. Please provide a breakdown of estimated staff and wages in the following categories: Full Time Part Time Volunteers $ $ 4. Do you employ contractors subcontractors?Yes D or a) Estimated annual payment Labour Only I $ I Labour & Plant I $ I c) Precautions taken to identify the adequacy of the Liability and Workers' Compensation insurance arrangements page 3 of 5 ~ Marsh McLennan & Companies ~ Coverage for liability assumed under agreement or contract will be limited to lease liability or liability assumed under a warranty of fitness or quality as regards your products. You should ensure that You are noted as a Principal on all Contractor's and/or Sub-contractors Liability Insurance Covers. Are you always named as Principals on Contractors and/or Sub-contractors Liability policy? Yes D PROPERTY Buildings and Contents Do you wish to insure Contents? NoD I$ I If "Yes" please provide the total value of Contents to be insured Do you have any individual items valued greater than $5,OOO? If "Yes", please list all individual items and the value. Yes D Are you required to insure Buildings? Yes D I$ I If "Yes" please provide details of the replacement value of each Building(s) to be insured Please advise the security details of each premises, ego Deadlocks, Local Alarms, Back to Base Alarm etc. Please advise the Fire protection installed in each premises, ego Extinguishers, Sprinkler Systems Have you ever had a claim in the last 5 years? If "yes", please provide details: page 4 of 5 ~ Marsh McLennan & Companies ~ The law requires you to tell an Insurer everything you know (or could reasonably be expected to know in the circumstances) which is relevant to the insurer's decision to insure you and the terms on which they insure you. This duty applies before you enter into a contract with an Insurer, that is, before an insurer accepts your proposal and also each time before you alter or renew the Policy. Each person named as the Insured has the same duty. PENAL TV FOR NON-DISCLOSURE If you fail to comply with your duty of disclosure, the Insurer may: reduce or refuse to pay a claim: or cancel your Policy. act dishonestly, the Insurer may invalidate the Policy from the beginning and not be bound by it. If you You don't need to tell us anything which: reduces the risk: is common knowledge: we already know, or ought to know in the ordinary course of our business: or we indicate we do not want to know. If you are not sure that something is relevant, it is best to disclose it anyway. UTMOST GOOD FAITH Every contract of insurance is based on the utmost good faith requiring each part (ie. you and the Insurer) to act towards the other party in respect of any matter arising under the contract, with the utmost good faith. If you fail to do so you may prejudice any claim. INADEQUATE SPACE TO ANSWER If there is inadequate space to answer our General Information or other questions or you need to disclose something to us because of your Duty of Disclosure, please attach a separate piece of paper to this application giving full details of additional information. 1. The Duty of Disclosure, Non-Disclosure and Inadequate Space to Answer notices set out above have been read by me/us. 2. All answers and statements made in this application are true and accurate in every respect and no information withheld which is likely to affect the Insurer's decision about accepting this insurance. has been 3. I acknowledge the Insurer reserve the right to decline any application. Applicant's Signature II Date I I II Applicant's Title page5 of5 ~ Marsh Mclennan & Companies