IMPORTANT NOTICE
Failure to disclose all material information that is likely to influence the acceptance of the risk or the terms applied could invalidate the insurance. If you are in any doubt as to whether any information is material, it should be disclosed. Where the space provided is insufficient for your replies, please provide these separately and attach to this Supplementary Proposal Form. Reference to Insured in this Addendum means: the entity or entities named in question 1 of the Proposal and this Addendum the past and/or present employees or principals of the entity or entities; and the directors of the entity or entities and all subsidiary entities for whom cover is required.
Proposed Insured:
Date that the original Proposal Form was signed and dated, with which this Addendum attaches to :
If the Proposed entity is a Licensed Insurance Broker:
Please state the Financial Services License Number:
Is the Entity licensed to transact General Insurance?	Yes No
Is the Entity licensed to transact Life Insurance?	Yes No
Is the Entity licensed to transact any other Financial Products?	Yes No
If “Yes” please provide details:
In the table below – please list all Authorised Representatives involved in the Proposer’s business (including all Corporate Authorised Representatives), indicating whether any individuals are salaried employees or paid on commission:
Full Name	ASIC Authorised Rep. Number	Salaried? Yes/No	Commission? Yes/No
Does the Proposer act as an Underwriting agent or hold any binding Authorities?	Yes No
If “Yes”, how many?
If so, for each facility state the security, the products and the limits involved:
Class of Business
Max Limit of Binding
Underwriter
Does any facility provide any claims handling authority?	Yes No
If “Yes”, please note Class of Business & Authorised Limit for Claims Settlement:
Has an audit ever been carried out in respect of any facility?	Yes No
If the answer to c) was “Yes’, please answer the following?
When was the last audit carried out?
Were any audit fining made known to you?	Yes No
What recommendations/requirements did the auditor or Insurer make as a result of the audit?

Have all audit recommendations been actioned?	Yes No
If “No”, please state why recommendations have not been actioned?
Does the Proposer place any insurance with Unauthorised Insurers/DOFI’s?	Yes No
If “Yes” please provide details:
Is the Proposer a member of an Industry cluster group?	Yes No
If ‘Yes”, please state which:
Please complete the following table, stating your income from the following? (please round to nearest dollar)
Financial Year	Brokerage / Commission	Policy Fees	Other Fees	Total
Previous	.......... / ..........	$	$	$	$
Current	.......... / ..........	$	$	$	$
Budgeted Next	.......... / ..........	$	$	$	$
Please state the Gross Premium processed for current year:	$
Please state Total Expenses for current year:	$
What proportion (as a percentage) of your Total Income is derived from provision of services to Retail clients?	%
Please show below, the gross premium as a percentage to total 100%, between all products for the last complete financial year:
Retail Household / Landlords
Retail Motor
Retail Other
Commercial Fire/Contents/Package
ISR
Professional Liability / D&O / Cyber / Management Liability
Light Commercial Motor (to 3 tonnes)
Heavy Commercial Motor (over 3 tonnes)
Liability
Aviation
Marine
Livestock
Workers Comp
Personal Accident
Life
Other (Please Specify below)
TOTAL	100 %

DECLARATION AND AGREEMENT I/We declare in relation to the facts, statements and particulars contained in this Addendum as follows: I/We have made all reasonable and necessary enquiries; I/We confirm that to the best of our knowledge and belief, they are true and complete; No material facts have been omitted, misstated, misrepresented or suppressed; and Should any of the information given by us alter between the date of this Addendum and inception date of the insurance to which this proposal relates, we will give immediate notice thereof to the insurer. I/we acknowledge that this Addendum forms part of the Proposal for insurance made by Us. I/We acknowledge receipt of the Important Notices on Page 1 contained on this Addendum Form and that we have read and understood the content of those Notices. I/We confirm that we are authorised by the Company and its Directors to complete, sign and submit this proposal on behalf of the Company and its Directors.
Name of Business:
Signature/s:
(This Proposal should be signed by a Principal, Partner or Director of Proposed Insured)
Title of Signatory:
Full Name of Such Person:
Date of Signing: