LEXi Renewals Important Information Who is completing the form?InsuredBroker Important Information for Broker PLEASE USE GOOGLE CHROME ONLY The intent of this on-line application is to replace the need for a broker’s full quote slip or a completed proposal form. It’s interactive such that the questions asked match the answers given. This has been designed so that you can easily complete it from your records, or by you with your client over the phone or by you when you visit them. A full copy of your answers will be automatically emailed to you upon completion and you are welcome to forward this to your client for their signature if required (we do not require this). You also have the option of getting the client to complete the form online themselves and a copy of their answers will be automatically sent to you for your records. Important Information for the Insured PLEASE USE GOOGLE CHROME ONLY USEThe intent of this on-line application is to replace the need for a a completed proposal form. A full copy of your answers will be automatically emailed to your broker and yourself upon completion. PRIVACYEdge is committed to the protection of your privacy and is bound by the National Privacy Principles for the handling of your information. Edge’s Privacy Policy can be viewed online by visiting our website (edgeunderwriting.com.au). YOUR DUTY OF DISCLOSUREBefore you enter into an insurance contract, you have a duty to tell us anything that you know, or could reasonably be expected to know, may affect our decision to insure you and on what terms. You have this duty until we agree to insure You. You have the same duty before you renew, extend, vary or reinstate an insurance contract. You do not need to tell us anything that: reduces the risk We insure You for; or is common knowledge; or we know or should know as an insurer; or we waive your duty to tell us about. If you do not tell us somethingIf you do not tell us anything you are required to, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both. If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed. PLEASE ANSWER ALL QUESTIONSPlease answer all questions fully and ensure all information requested is provided The Insured Expiring Policy No. * Expiry Date * Expiring Limits *$100,000 AOC / $250,000 Agg$250,000 AOC / $250,000 Agg$500,000 AOC / $500,000 Agg Renewal Limits Required (can pick more than 1 to receive alternate quotes) *$100,000 AOC / $250,000 Agg$250,000 AOC / $250,000 Agg$500,000 AOC / $500,000 Agg Name of the Insured *Only 1 entity per policy allowed Street Address * Suburb * State * Post Code * Actual Annual Turnover (last 12 months) * Estimated Annual Turnover (next 12 months) * T/O for S/Duty Purposes *100% of T/O comes from home state/territoryT/O comes from various states/territories Please provide T/O split by state so that the correct Stamp Duty calculation can be applied * Normal Business Activity * Cover Details Please advise any Additional Optional Benefits to apply to the renewalDisputes arising out of Building or Construction ContractsDisputes arising out of Employment Contracts with your EmployeesPersonal Legal Expenses Cover & Free Legal Advice for your Employees Number of Employees * Instructions & Broker Declaration Declaration Unreported Claims / Known Circumstances After appropriate enquiry, is the Insured aware of any unreported claim or any other incident / circumstance which may develop into a claim under the expiring or the new policy? Answer *NoYes Please provide full details * Material Changes With regards to the the Duty of Disclosure, are there any material changes to the nature of the risk being Insured? Answer *NoYes Please provide full details * Please Confirm *I have explained the Duty of Disclosure to my client The information provided is a true, accurate and complete reflection of the answers provided to me by my client I, the undernamed, hereby declare that: *I understand my Duty of Disclosure shown at the beginning of this formall answers and statements made in this Application are true, correct and complete in every respectwhere any part(s) of the Application has been completed by others, I have checked their answers and confirm they are true, correct and complete in every respectI give permission for Edge Underwriting or the Insurer to collect or disclose any personal information relating to this insurance to/from any other insurers or insurance reference serviceshould any information given by me alter between the date of this form and the inception/renewal date of the insurance to which this application relates, I shall give immediately notice thereofI am authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this application and I complete this application form on their behalf My Full Name * My Email Address * Broker's Name * Broking House * Broker's Email Address * Broker's Phone NumberPlease include area code if not providing mobile number Please provide any additional comments/requests here Submit to Edge Click HERE to view the coverage summary
