Unimutual Limited
ABN 45 106 564 372
AFS LICENCE No 241142
ADDITIONAL NOMINATED AFFILIATE QUESTIONNAIRE
1.0
1.1
1.2
1.3
1.4
1.5
1.6
1.7
GENERAL INFORMATION
Name of Affiliate
Please attach a copy of the affiliates latest published Annual Report and Audited Financial Statements.
Description of Activities:
University’s ownership of Affiliate (%)
Estimated total staff payroll (including on-costs)
for the affiliate for the current Protection Period
(1 Nov last year to 31 Oct this year).
Estimated income for the next Protection Period
(1 Nov this year to 31 Oct next year) (also
provide income earning activities)
Are all affiliate’s activities included in the current University’s business activity and
YES / NO
professional business descriptions?
If NO, provide details of any additional activities:
2.0
2.1
2.2
PROPERTY
Provide a listing of assets not currently included in the University’s asset listing.
Has the affiliate made any property claims over the last five years?
If YES, provide details:
3.0
3.1
GENERAL AND PRODUCT LIABILITY
Does the affiliate manufacture, sell or supply goods or products?
If YES, provide details in the table below.
YES/NO
YES / NO
Note: Include in the Description of Product column details of the product's end use, especially if the applicant's product is a
component part.
Note: Any products exported to USA or Canada (or any other territory coming within or subject to the jurisdiction of the courts of
USA or Canada) must be specifically declared showing a detailed product description and expected revenue for the Protection
Period.
Estimated
Estimated
revenue
revenue
(by country if
(by country if
Are the products designed,
applicable) for
Who is the product sold to
applicable) for
manufactured or packaged by
the next
Description of Product
(e.g. outside entity, public
the current
the Member? If so, please
Protection
Protection
etc.)?
Period (1 Nov
provide details.
Period (1 Nov
this year to 31
last year to 31
Oct next
Oct this year).
year).
3.2
Does the affiliate provide any services to external bodies such as maintenance services,
cleaning services, testing, servicing or repair of equipment, hair and beauty service?
If YES, complete table below:
Who Services are provided
to:
Description of Services
3.3
Annual Revenue (By country)
Does the affiliate own and/or operate student accommodation, residential colleges or
dormitories?
If YES, complete table below:
Name of
facility
Age of
building
Number of
storeys
Building
construction
Sprinkler
(Y/N)
Owner
YES / NO
Operator
YES/NO
Capacity
(in number of
students)
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3.4
Does the affiliate own, manage and/or operate sporting facilities such as grandstands,
indoor sporting facilities, gymnasiums, swimming pools etc.?
If YES, please complete table below:
Name of Facility
YES/NO
Maximum attendance
capacity (grandstands or
spectator stands only or total
capacity if indoor facility)
Location
Note: For the maximum capacity of grandstand or spectator stands or total capacity for the indoor facilities, please simply indicate
whether “200 or more” or “under 200”, if you have difficulty in obtaining the exact number.
3.5
3.6
Does the affiliate operate a tavern or other facilities where alcohol is sold?
If YES, please complete the following information.
What is the expected revenue for the Protection
Period from such licensed premises?
Projected for next
Protection Period
or Estimated Actual for
current Protection Period
(1 Nov this year to 31 Oct
next year)
(1 Nov last year to 31 October
this year)
4.2
Number of
carers
Number of
licensed
places
Age Range of
children
YES/NO
Operating Hours (indicate one
or two shifts per day)
Annual Turnover/Revenue
Has the affiliate had a claim made against them for general or product liability in the last 5
YES / NO
years?
If YES, please complete the table below by providing details of all such claims and specify in the column
for claimant details who it was that the claim was made against e.g. applicant, nominated affiliate (name),
individual staff member (name) etc.
Date of
Loss (when
the injury or
damage
occurred)
4.0
4.1
Please split the revenue into
food sales, bottle shop and bar
sales
Does the affiliate own and/or operate a child care facility?
If YES provide details below:
Name of
Facility
3.7
YES / NO
Claimant
Details
Who was
claim
made
against?
Brief
description of
the claim
Amount
Paid
Amount
Outstanding
Total
Incurred
Amount
Retention/
Deductible
that applied
to the claim
PROFESSIONAL INDEMNITY
Does the affiliate provide any professional consulting services?
YES/NO
If YES please provide details.
Has the affiliate had a claim made against them for professional liability/indemnity in the
YES/ NO
last 5 years?
If YES, please complete the table below by providing details of all such claims and specify in the column
for claimant details who it was that the claim was made against e.g. applicant, nominated affiliate (name),
individual staff member (name) etc.
NOTE: Date of Loss refers to the date when the applicant, nominated affiliate or their staff or students first became aware of the
facts or circumstances giving rise to the claim or the date when the claim was made by third party, whichever is the earlier.
Who was
Retention/
Brief
Total
Date of
Claimant
claim
Amount
Amount
Deductible
description of
Incurred
Loss
Details
made
Paid
Outstanding
that applied
the claim
Amount
against
to the claim
5.0
5.1
MANAGEMENT LIABILITY
In the past 5 years has the affiliate been the subject of any investigation by any
Regulatory or Official Body or Institution?
YES / NO
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5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
6.0
6.1
6.2
6.3
Has the affiliate ever had an insurer decline a proposal, impose special terms, or cancel
or refuse to renew a Directors & Officers Liability Policy or an Employment Practices
Liability Insurance Policy?
Is the affiliate currently:
 insolvent (liabilities exceed assets)?
 unable to pay its debts as they fall due?
 in liquidation, the subject of an outstanding winding-up petition or issued notices of a
meeting to consider a resolution for liquidation?
 the subject of an administration or application for an administrative order?
If YES, to any of the above please give full details:
Have all revenue recognition practices used by the affiliate been approved by their
respective external auditor?
Does the affiliate have any assets permanently located in, or business activities in, the
USA or Canada?
Has an Auditor’s Report ever been qualified in any way for the affiliate?
In the last five years, has the affiliate changed its external auditor?
Does the affiliate intend to change its external auditor in the next 12 months?
Has any Director or Officer of the affiliate ever been subject to any prosecution,
disciplinary action, been fined or penalised or ever been the subject of an inquiry and/or
investigation in their capacity as a Director or Officer of the affiliate?
Has there ever been, or is there now pending, a claim against any Director or Officer of
the affiliate, in their capacity as Directors or Officers of the affiliate?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
YES/NO
FORM COMPLETED BY
Name:
Position:
Date:
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