STRATHEARN INSURANCE BROKERS by benbenzhou

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									                            QBE INSURANCE (AUSTRALIA) LIMITED
                            ABN 78 003 191 035




                                                                                               Mineral Exploration Facility
                                                                                                    Insurance Application
Notice to the Applicant
This notice must be read before you complete the application form. (Pursuant to the provisions of the Insurance Contracts Act 1984)


 Your duty of disclosure – contracts of general insurance
 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 be expected to know, is relevant to the Insurer‟s decision
 whether to accept the risk of the insurance and , is 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 any matter:-
 – that diminishes the risk to be undertaken by the Insurer;
 – that is of common knowledge;
 – that your Insurer knows or, in the ordinary course of their business, ought to know;
 as to which 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 their 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.
 Utmost good faith
 Every insurance contract is subject to the doctrine of utmost good faith which requires that parties to the contract should act toward
 each other with the utmost good faith. Failure to do so on your part may prejudice any claim or the continuation of cover provided by
 the Insurer.
 Claims made during the period of insurance
 Section 4 of this policy provides cover on a “claims made” basis, which means that claims first advised to you (or made against you)
 during the period of insurance are covered, provided that the incident that caused the claim occurred after the Retroactive Date and
 provided that the claim falls within the coverage afforded under the Policy.
 Not a renewable contract
 Cover under this policy will terminate at expiry of the Period of Insurance specified in your policy document. If you wish to effect
 similar insurance for a subsequent period, it will be necessary for you to complete a new proposal form prior to the termination of the
 current policy so that terms of insurance and quotation(s) can then be developed for your consideration.
 Change of risk or circumstances
 It is vital that you should advise us of any departure from your “normal” form of business (ie. that which has already been conveyed
 to the Insurer). For example, acquisitions, changes in location or new overseas activities.
 Subrogation
 You may prejudice your rights with regard to a claim if, without prior agreement from the Insurer, you make agreement with a third
 party that will prevent the Insurer from recovering the loss from that, or another party.
 Your policy contains provisions that exclude the Insurer from liability, or reduce their liability, if you have entered into any
 agreements that exclude your rights to recover damages from another party in relation to any loss, damage or destruction which
 would allow you to sustain a claim under this policy.




QM1607-0907                                                               Page 1 of 19
 Contents

 Please select Sections of cover required for your business and complete the information required for each policy:-

     Section       Class of Insurance                                                Page Number             Cover Required

        1          General Information                                                    3                Must be Completed

        2          Commercial Motor Vehicle                                               4                   Yes     No

        3          Corporate Travel                                                       5                   Yes     No

        4          Directors‟ and Officers‟ Liability                                     6                   Yes     No

                   Expatriate Medical and Repatriation Expense                            8                   Yes     No
        5
                   Inpatriate Medical and Repatriation Expenses                           8                   Yes     No

        6          General Property                                                       9                   Yes     No

        7          Office Package                                                         9                   Yes     No

        8          Personal Accident (Journey Gap)                                       10                   Yes     No

        9          Personal Accident (Working Directors)                                 11                   Yes     No

        10         Personal Accident and Illness (24 Hour)                               12                   Yes     No

        11         Public Liability                                                      13                   Yes     No

        12         West Australian Workers‟ Compensation                                 14                   Yes     No

        13         Declaration and Authorisation                                         16                Must be Completed

                   Personal Accident and Illness (24 Hour)
   Annexure 1                                                                            17                   Yes     No
                   (to be completed by each employee for Section 10)

                   Public Liability – To be completed when insuring Subsidiary
   Annexure 2                                                                            19                   Yes     No
                   Companies or Joint Venture projects


A request to provide a quotation on any class of insurance does not oblige you to take any insurance.




QM1607-0907                                                           Page 2 of 19
 SECTION 1: General Information
 Details of the applicant
 Name(s) of
 Insured(s) in full

 Tax Status             Registered Business Yes         No         ABN                                               Taxable             %
 Contact Number(s):     Phone No.      (      )                                          Fax No.   (       )

 Postal Address
                                                                                        State                  Postcode

 Street Address
                                                                                        State                  Postcode
 Website Address                                                            Email


 General Information
 Has the Applicant had any insurance declined or cancelled, application rejected, renewal refused, claim rejected,
                                                                                                                          Yes   No
 special conditions or special excess imposed by an insurer? If “Yes”, please supply details




 When was the business first established
 Were any of your subsidiary companies incorporated outside of Australia? If “Yes”, please list details below             Yes   No




 Do you intend to undertake any Bankable Feasibility studies within the next 12 months?                                   Yes   No


 AMEC Members
 Is your organisation a Member of the Association of Mining and Exploration Companies Inc (AMEC)                          Yes   No


 Claims History
 Has the applicant had any claims made against you during the last 5 years? If “Yes”, please supply details               Yes   No




 Description of Business
 Principally, mineral explorer, tenement holder, property owner and occupier and all related activities.
 Are there any other activities in which your company is engaged? If “Yes”, please describe the activities below.         Yes       No




 Are you involved in any mining production activities? If “Yes”, please describe the activities below.                    Yes   No




 Are exploration activities being undertaken in overseas countries? If “Yes”, please name the countries below.            Yes   No




 Please provide exploration expenditure percentage split by Territories in Australia and Countries (must equal 100%)
 Territory / Country                                                                                                      Percentage
                                                                                                                                %
                                                                                                                                %
                                                                                                                                %




QM1607-0907                                                              Page 3 of 19
 SECTION 2: Commercial Motor Vehicle
 Period of Insurance             From        /   /               To                /   /     at 4 p.m.


 Details to be completed for all vehicles
 (1) Motor Vehicle(s)                   If insufficient space, attach list
                                                                                                                Cover Required
                                                                                    Sum
        Year       Make and Model          Body Type            Reg. No.                    State                            Third Party
                                                                                  Insured                Comprehensive
                                                                                                                                Only
(i)                                                                           $
(ii)                                                                          $
(iii)                                                                         $
(iv)                                                                          $
(v)                                                                           $

 (2) Windscreens are covered under comprehensive cover, but subject to policy deductible.
     If no deductible is required an additional premium of $50 will be payable. Is this option required?                 Yes       No
 (3) Give details including values of standard or non-standard equipment such as stereo systems and special tool
                                                                                                                             Sum Insured
     kits for which you require cover
                                                                                                                         $
                                                                                                                         $
                                                                                                                         $
 (4) Has any vehicle been modified from the manufacturers specification so that its performance is altered?              Yes       No
     If “Yes”, give detail




 (5) Are any vehicles goods carrying? If “Yes”, give details of goods carried.                                           Yes       No




 (6) Have any of the proposed drivers had any convictions or fines in the last 5 years for the following:
     (please select where appropriate)
         Alcohol                                                                                                         Yes       No
         Negligent driving                                                                                               Yes       No
         Dangerous driving                                                                                               Yes       No
         Any criminal offences                                                                                           Yes       No
         Licence suspended, cancelled, reduced for any reason                                                            Yes       No
 If you have answered “Yes” to any of the above, please provide full details including the driver‟s name




 Basis of Settlement
 For all vehicles the Basis of Settlement will be at our option to repair, reinstate or pay the amount of the loss of or damage to your
 vehicle plus standard accessories and those included on the schedule provided such payment does not exceed the Market Value at
 the time of the loss but limited to the amount shown on the Schedule for each vehicle.



QM1607-0907                                                                  Page 4 of 19
 SECTION 3: Corporate Travel
 Period of Insurance           From            /   /              To              /   /             at 4 p.m.


 Coverage options

 (a) Accident and Illness Weekly Benefit Limit Option (please select)
     Option A     $500,000 Death and Capital Benefits and $1,500 per week
     Option B     $500,000 Death and Capital Benefits and $4,000 per week
     Option C     $1,000,000 Death and Capital Benefits and $4,000 per week


 Details to be provided
 (b)   Is cover required for “Fly-In / Fly-Out” Travel?                                                                Yes      No

 (c)   Is cover required for “non employees” i.e. consultants or invitees?                                             Yes      No

 If you have answered “Yes” to any question, please detail and include them in your travel estimates below (1 person = 1 return trip)

              Destination                      Number of Trips                 Average Duration (days)           Total Days

 Intrastate

 Interstate

 Overseas

 Charter flights

 Other

 Total

 (d) What is the estimated maximum number of employees (and spouses) that will travel together on the one
     conveyance during the period?

 (e)   Is there a company policy on how many directors / senior staff (and spouses) are allowed to travel together?
                                                                                                                      Yes      No
       If “Yes”, please detail




 (f)   With regard to charter flights

         Origin and destination points of charter flights (could you please advise estimated distance)



         Type of aircraft being utilized (single, twin engine) and name of charter company



         Type of landing strip and facilities at the destination point (public or private strips)



         Average number of insured persons on any one charter flight



         Maximum number of insured persons on any one charter flight



         Number of helicopter flights undertaken (if any)



 (g)   Will any trip be in excess of 90 days?                                                                         Yes      No



QM1607-0907                                                                  Page 5 of 19
 SECTION 4: Directors and Officers Liability
 Period of Insurance         From           /    /           To             /   /         at 4 p.m.


 Limit of Liability

 Please select the Limit of Liability required
 $ 1,000,000
 $ 2,000,000
 $ 5,000,000
 $10,000,000


 Details of Board of Directors

 Please note: If your application contains the most recent annual report of the Corporation and the Board of Directors remains
 unchanged from that annual report then it is not necessary to complete this question. Simply select the appropriate box below.
 Details of the Board of Directors of the Corporation are:
     in the attached annual report              detailed below

                 Name of Director                                       Qualifications                        Age        Date Appointed
                                                                                                                               /   /
                                                                                                                               /   /
                                                                                                                               /   /
                                                                                                                               /   /
                                                                                                                               /   /


 Financial Position of the Corporation
 (a) Has there been any change in the financial position or capital structure of the Corporation or is there any trend
     or event not reflected in the annual report and financial statements attached to this proposal, that might           Yes      No
     materially affect the financial position shown in those statements?
 (b) Is any proposed insured person aware of facts or circumstances that might affect the ability of the Corporation
                                                                                                                         Yes       No
     to meet all its debts as and when they fall due?
 If you have answered “Yes” to either part (a) or (b) above, please supply details.




 Claims History of Directors and Officers
 (a) Has there been, or is there now pending, any claim against any proposed insured person, in their capacity as
                                                                                                                          Yes      No
     a Director or Officer of either a Corporation, or any other company, organisation, or trust?
 (b) Do any circumstances exist that might give rise to a claim against any proposed insured person?                     Yes       No
 If you have answered “Yes” to either part (a) or (b) above, please supply details.




 Claims History of Corporation
 (a) Has there been, or is there now pending, any action, litigation or other proceedings against the Corporation,
     including any action, litigation or other proceedings brought under or pursuant to any Commonwealth, State or        Yes      No
     Territory legislation?
 (b) Has there been, or is there now pending, any investigation, examination, inquiry or other proceedings in
                                                                                                                         Yes       No
     relation to the affairs of the Corporation?
 If you have answered “Yes” to either part (a) or (b) above, please supply details.




QM1607-0907                                                            Page 6 of 19
 Shareholder Information
 Does any shareholder, or associated group of shareholders, own or control (directly or beneficially) more than ten
                                                                                                                        Yes   No
 percent (10%) of the share capital of the Corporation?
 If you have answered “Yes”, please supply details.




 Merger, Acquisition of Takeover Activity
 (a) Has the Corporation been involved in any merger, acquisition, takeover or divesture in the last three (3) years?   Yes   No
 (b) Is the Corporation considering any acquisition, takeover or divesture proposal at present?                         Yes   No
 If you have answered “Yes” to either part (a) or (b) above, please supply details.




 U.S.A. and/or Canada Operations
 Does the Corporation conduct any business in
 (i) the United States or any of it‟s territories or protectorates?                                                     Yes   No
 (ii) Canada or any of its territories or protectorates?                                                                Yes   No
 If “Yes”, please supply the following details
 (a) Total assets held in U.S.A.                                                                                        $
 (b) Total assets held in Canada:                                                                                       $
 (c) Are the shares of the Corporation traded on any USA Stock Exchange?                                                Yes   No
 (d) Are the shares of the Corporation traded on any Canadian Stock Exchange?                                           Yes   No
 (e) Does the Corporation have any American Depository Receipts traded in the USA?                                      Yes   No


 Insurance Cover
 (a) Does the Corporation presently carry, or has the Corporation ever carried, Directors and Officers Liability
                                                                                                                        Yes   No
     Insurance?
 If “Yes”, please supply details:-
 Insurer
 Expiry Date                             /   /
 Limit of Indemnity                  $
 Premium                             $




QM1607-0907                                                            Page 7 of 19
 SECTION 5: Expatriate / Inpatriate Medical and Repatriation Expenses
                       Expatriate                          Inpatriate

 Period of Insurance           From           /   /              To                 /   /        at 4 p.m.


 Please select the Aggregate Limit of Liability required                    $ 1,000,000
                                                                            $ 2,000,000


 Insured Person/s
 Person                       Name                                                                                            Date of Birth
 Employee                                                                                                                          /   /
 Spouse                                                                                                                            /   /
                                                                                                                                   /   /
 Dependant Children
                                                                                                                                   /   /
 Contact Number                                                    Phone Number                              Phone Number
 Overseas (if known)                                               (Private)                                 (Business )


 General Details
 (a) Usual country of domicile
 (b) Country of posting
 (c) Cover to incept from                                               /       /
 (d) Period of contract/cover in intended country                       /       /       to   /     /
 (e) Employee‟s occupation
 (f) Employee‟s annual wages                                       $


 Medical History
 Please note, pre-existing medical conditions (including pregnancy prior to cover inception) are automatically excluded from policy
 coverage. All possibilities must be considered prior to departure. Please disclose your or any accompanying family members
 medical history as follows:
 Have you or any family member accompanying you:-
 (a) ever had any disorders which affected your heart, lungs, bowels, bladder, liver, kidneys, blood circulation,
                                                                                                                             Yes       No
     digestive system, genitals, back, ears or eyes?
 (b) ever had any nervous disorder, paralysis, rheumatism, tuberculosis, ulcer or cancer?                                    Yes       No
 (c) lost all or part of a limb or have any other physical defect or infirmity?                                              Yes       No
 (d) had any other illness, injury, operation or treatment in the last 5 years which required hospitalisation?               Yes       No
 (e) claimed for benefits under any accident or illness policy?                                                              Yes       No
 Is there any likelihood of recurrence of any illness or injury previously suffered or the possibility of you or             Yes       No
 an accompanying family member undergoing surgery or other treatment?
 Do you or any family members take medication or drugs on a regular basis?                                                   Yes       No
 Do you or any family members intend to engage in any hazardous pursuits or pastimes including but
                                                                                                                             Yes       No
 not limited to motor sports, rock climbing, water skiing or horse riding?
 NOTE:        If any of the above were answered “Yes”, please provide details including description of injury or illness, duration (dates),
              the cause, nature of treatment and results, current condition, name and addresses of doctors and hospitals consulted.




QM1607-0907                                                                   Page 8 of 19
 SECTION 6: General Property

 Period of Insurance        From            /   /            To             /   /         at 4 p.m.


 Details of the interest insured
 Please attach a schedule of items (including make, model and serial numbers) for all electronic               Sum Insured
 items exceeding $1,000 in value
                                                                                                      Australia wide    Worldwide
 Laptops                                                   Number of Units                                              $
 Other electronic equipment such as mobile phones, GPS, electronic survey equipment                                     $
 Non electronic equipment such as generators, camping equipment etc...                                                  $


 Excess
 Each and every claim                                                                                                           $250




 SECTION 7: Office Package

 Period of Insurance        From            /   /            To             /   /         at 4 p.m.


 Details of the Business/Premises
                        Select if same as street address (as shown in General Information section)
 Location 1.                                                                              State                      Postcode
 Location 2.                                                                              State                      Postcode
                                                                                                       Location 1.       Location 2.
 Fire and Theft     Is the section of premises occupied solely by you protected by:                     Please select       Please select
 Protection
                    1. Fire sprinkler system                                                           Yes     No        Yes       No
                    2. Fire extinguishers                                                              Yes     No        Yes       No
                    3. Burglary alarm system                                                           Yes     No        Yes       No
                    4. Deadlocks on all external doors                                                 Yes     No        Yes       No
                    5. Bars on all external windows                                                    Yes     No        Yes       No


 Property Section (including fire, perils, theft and accidental damage)
 Interest Insured                                                                                      Location 1.       Location 2.
 Building                                                                                              $                 $
 Contents                                                                                              $                 $
 Replacement or restoration of records and documents                                                   $                 $


 Business Interruption
 Interest Insured                                                                                                       Sum Insured
 Additional increase in cost of working             Indemnity Period                  months                            $
 Claims preparation costs                                                                                               $




QM1607-0907                                                            Page 9 of 19
 Money
                                                                                                    Location 1.     Location 2.
 Please select limit required:-                                                                     $1,000          $1,000
                                                                                                    $3,000          $3,000
                                                                                                    $5,000          $5,000
 Note: Money outside safe outside business hours is limited to $500


 Glass
 Interest Insured                                                                                   Location 1.     Location 2.
 External glass                                                  Yes       No                       Yes      No     Yes        No
 Internal glass                                                  Yes       No                       Yes      No     Yes        No
 Sum Insured: Replacement value




 SECTION 8: Personal Accident (Journey Gap)

 Period of Insurance        From          /   /             To               /   /      at 4 p.m.


 General Details
 This policy provides cover for employees who may be injured whilst in a direct journey between their home and place of work either
 at the start or end of their day‟s work


 Employee Details
 Please provide the following information for coverage to be affected
 State / Territory in Australia                                                                               Number of Employee




 Benefit                                                                                Option 1                    Option 2
 Death and Capital Benefits                                                             $100,000                    $200,000
 Weekly Accident and Sickness                                                            $1,000                      $1,500
 Benefit Period                                                                         104 weeks                  104 weeks
 Death and Capital Benefits                                                             $100,000                    $200,000
 Please select option required




QM1607-0907                                                             Page 10 of 19
 SECTION 9: Personal Accident (Working Directors)

 Period of Insurance       From           /   /               To              /   /        at 4 p.m.


 General Details
 This policy provides cover for Directors of Publically Listed Companies who are no longer covered under the Workers Compensation
 and Injury Management Act 1981.
 Cover is only available for persons under 65 years of age unless special acceptance is obtained.


 Cover Provided
 Personal Accident cover for Directors as follows:-.
 Benefit                                                                                 Option 1                    Option 2
 Death and Capital Benefits                                                              $200,000                    $400,000
 Weekly Accident and Sickness                                                             $2,000                      $4,000
 Medical Expenses                                                                           Nil                            Nil
 Excess Period                                                                              Nil                            Nil
 Benefit Period                                                                         104 Weeks                   104 Weeks
 Aggregate Limit                                                                        $2,000,000                  $4,000,000


 General Details
 Please provide the names of Directors and other information as requested below
                                                                                         Cover Option           % Time         % Time
 Name of Director                                         Position held
                                                                                      Option 1      Option 2   in Office     In the Field

                                                                                                                     %                %

                                                  Date of Birth       /   /            Height            Cm    Weight                 Kg

                                                                                                                     %                %

                                                  Date of Birth       /   /            Height            Cm    Weight                 Kg

                                                                                                                     %                %

                                                  Date of Birth       /   /            Height            Cm    Weight                 Kg

                                                                                                                     %                %

                                                  Date of Birth       /   /            Height            Cm    Weight                 Kg

                                                                                                                     %                %

                                                  Date of Birth       /   /            Height            Cm    Weight                 Kg

                                                                                                                     %                %

                                                  Date of Birth       /   /            Height            Cm    Weight                 Kg




QM1607-0907                                                           Page 11 of 19
 SECTION 10: Personal Accident and Illness (24 Hour)

 Period of Insurance        From           /   /           To             /   /            at 4 p.m.


 General Details
 As an alternative to Journey Gap and Working Directors Personal Accident, it is possible to insure Employees and Directors on a
 24 hour basis.


 Cover options available
 Benefit                                                                       Option 1          Option 2       Option 3       Option 4
 Death and Capital Benefits                                                   $100,000           $200,000       $300,000       $400,000
 Weekly Accident and Sickness                                                     $1,000          $2,000         $3,000         $4,000
 Medical Expenses                                                                    Nil           Nil             Nil            Nil
 Excess Period                                                                    7 days          7 days         7 days         7 days
 Benefit Period                                                               52 Weeks           52 weeks       52 weeks       52 Weeks


 Employee Details
                                                                                                                             Preferred
 Name of Employee                                                                 White Collar           Grey Collar
                                                                                                                           Option Number




 Annexure 1 – Please refer to page 17 if cover is required for this section
 Individual Personal Accident and Illness (24 Hour) proposal to be completed for each employee
 Cover is only available for persons under 65 years of age unless special acceptance is obtained.
 Cover is not available for pre-existing conditions




QM1607-0907                                                          Page 12 of 19
 SECTION 11: Public Liability
 Period of Insurance         From           /    /            To             /   /          at 4 p.m.


 Annexure 2 – Please refer to page 20 if cover is required for Subsidiary Companies or Joint Venture projects
 Cover is only provided when an entity is named on the schedule


 Limit of Liability

 Please select the Limit of Liability required          $ 5,000,00                      $10,000,000                       $20,000,000


 Estimated Annual Expenditure (including Subsidiaries and Joint Venture projects)
 Direct exploration expenditure eg. surveys, drilling companies (excluding joint ventures)                                 $
 Payroll                                                                                                                   $
 Contractors and Consultants                                                                                               $
 Overheads                                                                                                                 $
 Total Annual Expenditure                                                                                                  $
 Are there any existing open cut or underground mine workings on your tenements?                                           Yes       No
 If “Yes”, please provide details




 Is there any security or systems to prevent third parties from entering open cut or underground mine workings?            Yes       No
 If “Yes”, please provide details




 Will there be any exploration activities taking place underground during the period of insurance?                         Yes       No
 If “Yes”, please provide details




 Will there be any bulk sampling or blasting taking place during the period of insurance?                                  Yes       No
 If “Yes”, please provide details




 Care Custody and Control
 Coverage is provided for property (excluding any vehicle which is registered or which is required to be registered or hired in down
 hole tools) in your physical or legal control for the purpose of repair, service or which is a on temporary hire or loan to you, subject to
 a maximum indemnity of $100,000
 Do you require an amount in addition to the above limit?                                                                  Yes       No
 If „Yes‟ please provide details




 Contractual Liability
 Coverage for liability assumed under agreement or contract will be limited to lease liability or liability assumed under specifically
 agreed contracts.
 Do you assume liability under contract or hold others harmless (other than lease liability)?                              Yes       No
 If “Yes”, please provide details and attach copies of all agreements (other than lease liability). Coverage will be provided only if
 specifically agreed by QBE Insurance.




QM1607-0907                                                             Page 13 of 19
 SECTION 12: West Australian Workers’ Compensation
 Period of Insurance        From           /   /            To             /   /         at 4 p.m.


 General Information
 Please answer “Yes” or “No” to the following questions in relation to your business:-
 Pre-employment medicals                                                                                            Yes      No
 Have any charges been laid for breaches of the OH&S legislation in the past 5 years?                               Yes      No
 Have you any employees likely to work overseas?                                                                    Yes      No
 If “Yes”, which country?


 Details of Wages / Claims
 Note: “Wages” means ALL amounts paid including overtime, bonuses, commission and allowances.
         Please refer to the legislation in your jurisdiction for a complete definition.
 Details of wages / claims over the past 5 years.
                                                                                                                  Total Claim
   Policy           Employee                                                                  Total Claim
                                        Actual Wages Paid        Number of Claims                                  Amounts
    Year            Numbers                                                                  Amounts Paid
                                                                                                                  Outstanding
                                       $                                                 $                    $
                                       $                                                 $                    $
                                       $                                                 $                    $
                                       $                                                 $                    $
                                       $                                                 $                    $


 Working Directors
 Working Directors of publicly listed companies are no longer insured under Workers‟ Compensation legislation, however working
 Directors of unlisted companies can be insured provided that they are individually declared along with their remuneration.


 Estimated Wages
 Please complete the following table detailing estimated wages for the period but excluding any wages declared for Working
 Directors:-
                                                                                              Estimated            Number of
               Group                                      Location
                                                                                               Wages               Employees
 General                                                                                 $
 Clerical                                                                                $
                                                                                         $
                                                                                         $
                                                                                         $
                                                                         Total Wages     $




QM1607-0907                                                           Page 14 of 19
 Contractors / Sub-Contractors
 (a) Do you expect to contract out any of the work in connection with the business?                                         Yes           No
 (b) If the answer to (a) is “Yes”, will you satisfy yourself that contractors / sub-contractors are insured for workers‟
                                                                                                                            Yes           No
     compensation by obtaining letters of indemnity from them and their insurer?
 (c) Alternatively, do you wish to include such indemnity in the insurance now proposed
                                                                                                                            Yes           No
     If “Yes”, please complete the following in respect of the proposed period of insurance

 Name of Contractor /                                                                          Estimated Wages
 Sub-Contractor and             Location                                                 Labour and      Labour and         Labour, plant
 Nature of Work                                                  Labour only
                                                                                         plant           materials          and materials
                                                                 $                       $               $                  $
                                                                 $                       $               $                  $
                                                                 $                       $               $                  $
                                                                 $                       $               $                  $
                                                                 $                       $               $                  $
                                                                 $                       $               $                  $
                                                 Total Wages     $                       $               $                  $



 Details of Previous Insurer
 Have all outstanding premium payments been finalised with your previous insurer?                                           Yes           No
 Has any insurer permitted withdrawal of or declined any insurance?                                                         Yes           No
 Has any insurer cancelled or refused to renew a Policy?                                                                    Yes           No
 If “Yes”, which insurer, what reasons were given?




                                     Name of Previous Insurer                                            Policy Number          Due Date
 Last Year                                                                                                                        /   /
 One Year Ago                                                                                                                     /   /
 Two Years Ago                                                                                                                    /   /
 Do you employ workers in any other State?                                                                                  Yes           No
 If “Yes”, please name states
 Northern Territory                                                                                                         Yes           No
 South Australia                                                                                                            Yes           No
 Australian Capital Territory                                                                                               Yes           No
 Victoria                                                                                                                   Yes           No
 New South Wales                                                                                                            Yes           No
 Queensland                                                                                                                 Yes           No
 Tasmania                                                                                                                   Yes           No




QM1607-0907                                                              Page 15 of 19
 SECTION 13: Declaration And Authorisation

 Declaration and Authorisation

 1. The Duty of Disclosure, Non-Disclosure, 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 has been
    withheld which is likely to affect QBE‟s decision about accepting this insurance.
 3. I/We acknowledge QBE reserves the right to decline any application.

 I / We the undersigned authorised Applicant(s), after enquiry declare as follows:

 1. I am / We are authorised by each of the Applicants to make this Application
 2. I / We have read and understood the Notice to the Applicant on the front of this Application
 3. I / We have read this Application and the accompanying documents and acknowledge the contents of same to be true and
    complete
 4. I / We understand that, up until a contract of insurance is entered into, I am / We are under a continuing obligation to
    immediately inform QBE of any change in the particulars or statements contained in this Application or in the accompanying
    documents.

 Although the signing of this Application does not bind the Applicants to effect insurance, the Applicants acknowledge that the
 particulars and statements contain in this Application and in the accompanying documents shall be the basis of the contract should a
 Policy be issued, and further, the applicants acknowledge that the Application and the accompanying documents will be incorporated
 in the Policy.

 Signed, Chief Financial Officer                                                                                Date          /    /


 Please enclose with this Application:
 (a) The last 2 Annual Reports and financial statements (including audit report) of the applicant (if available on the website please
     ignore this request)
 (b) The last Interim Statement of the Applicant (if applicable)
 (c) Copy of the Indemnity Clause from the Applicant‟s Constitution



 Premium Details (Office use only)
                                                                           Fire                          Government
 Class of Insurance                                      Premium                             GST                                  Total
                                                                       Service Levy                      Stamp Duty
 Commercial Motor Vehicle                            $                         -        $                $                $
 Corporate Travel                                    $                         -        $                $                $
 Directors‟ and Officers‟ Liability                  $                         -        $                $                $
 Expatriate Medical Expenses                         $                         -        $                $                $
 Inpatriate Medical and Repatriation Expenses        $                         -        $                $                $
 General Property                                    $                 $                $                $                $
 Office Package                                      $                 $                $                $                $
 Personal Accident (Journey Gap)                     $                         -        $                $                $
 Personal Accident (Working Directors)               $                         -        $                $                $
 Personal Accident and Illness (24 Hour)             $                         -        $                $                $
 Public Liability                                    $                         -        $                $                $
 Workers‟ Compensation                               $                         -        $                $                $
 AMEC Discount                                       $                                  $                       -         $

 Total Premium Payable                               $                 $                $                $                $




QM1607-0907                                                            Page 16 of 19
 ANNEXURE 1: Personal Accident and Illness (24 Hour)
 Period of Insurance         From           /   /              To              /   /              at 4 p.m.


 General Details
 As an alternative to Journey Gap and Working Directors Personal Accident, it is possible to insure Employees and Directors on a
 24 hour basis. Each employee needs to complete a separate form.


 Cover provided (every Insured Person will need to complete their own form)
 Personal Accident cover as follows:-.
 Benefit                                                                            Option 1          Option 2        Option 3         Option 4
 Death and Capital Benefits                                                        $100,000           $200,000        $300,000         $400,000
 Weekly Accident and Sickness                                                          $1,000          $2,000          $3,000           $4,000
 Medical Expenses                                                                         Nil              Nil          Nil              Nil
 Excess Period                                                                         7 days          7 days          7 days           7 days
 Benefit Period                                                                    52 Weeks           52 weeks        52 weeks         52 Weeks
 Please select option required


 Personal Details (to be completed by the Insured Person)
 Name(s) of Insured(s)
 Date of Birth                      /   /                       Sex       M        F              Height         Cm           Weight           Kg
 Are you a permanent resident of Australia?         Yes      No       Your Occupation
 Describe your duties
 If you are self employed, how long have you been operating your current business?

 Name and address of
 Employer or Business                                                                     State                    Postcode
 Do you intend to work outside Australia? If “Yes”, please give details                                                          Yes      No




 Insurance and Medical Details
 1. Has any application for accident or illness insurance on your life ever been declined, modified,
                                                                                                                                 Yes      No
    accepted at an increased premium, cancelled or refused renewal?
 2. Have you ever claimed for benefits under any accident or illness policy?                                                     Yes      No
 3. Will you be entitled to claim under any other existing or intended insurance from any other source
                                                                                                                                 Yes      No
    providing for weekly benefits, workers‟ compensation or sick leave?
 4. Have you ever received medical advice, consulted a doctor, undergone any medical treatment or investigations
    for high blood pressure or cholesterol, any heart complaint or problem, HIV, AIDS or AIDS related conditions,
                                                                                                                                 Yes      No
    stroke, kidney, bowel, bladder or liver disease, cancer or tumour of any type, diabetes, asthma or any lung
    complaint, mental, nervous or depressive disorder, epilepsy, alcohol or drug abuse, nervous system disorder?
 5. During the last 5 years, have you suffered from any other health problem or physical impairment not
                                                                                                                                 Yes      No
    mentioned above or have your taken prescribed medication of any kind?
 6. Do you currently have any symptoms of ill health or injury or are you taking prescribed medication of any kind?              Yes      No
 7. Is there any likelihood of recurrence of any illness or injury previously suffered or the possibility of you
                                                                                                                                 Yes      No
    undergoing surgery or other treatment?
 If you have answered Yes to any of the above questions, please give details including description of injury or illness, duration
 (dates), the cause, nature of treatment and results, current condition, name and address of doctors and hospitals consulted.
 If there is insufficient space, please attach details.




QM1607-0907                                                               Page 17 of 19
 Activity Details
 Do you currently, or do you intend to engage in any hazardous pursuit or pastime, including but not limited to
                                                                                                                         Yes           No
 motor sports in any form, rock climbing, water skiing, horse riding, football (all codes), other body sports?
 If “Yes”, please give details




 Activity Details
 I have read and understood the important information and the policy wording. I declare that the information given is true and correct
 in every particular and all details relevant to this insurance have been disclosed. I understand that even if I have paid a premium,
 this cover will not be effective until QBE Insurance (Australia) Limited has accepted the insurance application and a Policy Certificate
 issued.


 Signature of Applicant                                                                                           Date         /   /




QM1607-0907                                                            Page 18 of 19
ANNEXURE 2: Public Liability
 Details of Subsidiary Company
 Name(s) of
 Insured(s) in full

 Business Description: Principally, mineral explorer, tenement holder, property owner and occupier and all related activities.
 Are there any other activities in which your company is engaged? If “Yes”, please describe the activities below.      Yes       No




 Country of Incorporation
 Place of Operation


 Details of Subsidiary Company
 Name(s) of
 Insured(s) in full

 Business Description: Principally, mineral explorer, tenement holder, property owner and occupier and all related activities.
 Are there any other activities in which your company is engaged? If “Yes”, please describe the activities below.      Yes       No




 Country of Incorporation
 Place of Operation


 Details of Joint Venture Company
 Name(s) of
 Joint Venture

 Business Description: Principally, mineral explorer, tenement holder, property owner and occupier and all related activities.
 Are there any other activities in which your JV company is engaged? If “Yes”, please describe the activities below.   Yes       No




 Name of Joint Venture
 partner
 Place of Operation
 Is the Joint Venture managed by you?                                                                                  Yes       No
 Are you required to arrange insurances for the JV‟s operations? If “Yes” please provide details of the covers
                                                                                                                       Yes       No
 required together with the “Insurance” and “Indemnity” conditions from the contract.


 Details of Joint Venture Company
 Name(s) of
 Joint Venture

 Business Description: Principally, mineral explorer, tenement holder, property owner and occupier and all related activities.
 Are there any other activities in which your JV company is engaged? If “Yes”, please describe the activities below.   Yes       No




 Name of Joint Venture
 partner
 Place of Operation
 Is the Joint Venture managed by you?                                                                                  Yes       No
 Are you required to arrange insurances for the JV‟s operations? If “Yes” please provide details of the covers         Yes       No
 required together with the Insurance and Indemnity conditions from the contract.



QM1607-0907                                                           Page 19 of 19

								
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