Journey Accident Insurance
Proposal Form

Keystone recommends that the proposed Insured keep a record of all information supplied for the purpose of entering into an insurance contract. Please answer all questions in full. If there is insufficient space, please provide further details on your letterhead. All attached documents form part of this Proposal.

General Details

Proposed Insured Name (list all entities including subsidiaries to be covered by the policy):

Street Address:

State:	Postcode:

Phone:	Website:

ABN/ACN:	Date of Establishment:

Business Activity

Please provide a detailed description of the business conducted by the proposed Insured. Attach any brochures or promotional material that may provide greater clarity in respect of the business.

Activity	Turnover %
%
%
%
%
100%

Has there been any substantial change in the proposed Insured's business in the past twelve months?	No ☐	Yes ☐
Does the proposed Insured anticipate any substantial change in activities during the next twelve months?	No ☐	Yes ☐
Has the proposed Insured had an insurance policy renewal declined or had any insurance policy cancelled for any reason within the last five years?	No ☐	Yes ☐
Has the proposed Insured or any principals of the proposed Insured ever been declared bankrupt?	No ☐	Yes ☐

If yes to any questions above, please provide full details in the space provided on page 3 of this Proposal.

Number of full time equivalent employees:

Accidental Death and Capital Benefits: $

Weekly Accident Benefit: $

Has the proposed Insured's employees had any accidents which were or could have been covered by the proposed insurance within the last five years?	No ☐	Yes ☐

If yes, please provide full details in the space provided on page 3 of this Proposal.

Declaration

After making appropriate enquiries, I declare that:

I am authorised on behalf of the proposed Insured(s) to complete this Proposal.

I have read and understood the Important Notices accompanying this Proposal.

Where I have provided information about another individual, I declare that the individual has been made aware of that fact and of the Keystone Privacy Statement.

I authorise Keystone to collect or disclose any personal information relating to this insurance to or from other insurers or insurance or credit reference services.

I confirm that the statements and information in this Proposal are true and complete.

I understand that, until a contract of insurance is entered into, I am under a continuing obligation to immediately inform Keystone of any change to the information contained in this Proposal.

I acknowledge that, if a contract of insurance is entered into, this Proposal and any accompanying documents will form the basis of the contract.

Name:	Signature:

Position:	Date: _____/_____/_____

Additional Information

Important Information

This Policy is issued by:

Keystone Underwriting Pty Ltd ABN 78 601 944 764 (Keystone)

Keystone Underwriting Pty Ltd is a Corporate Authorised Representative (No. 000468712) of:

Keystone Underwriting Australia Pty Ltd ABN 59 634 715 674 AFS License No: 518244

Who is the Insurer?

Certain Underwriters at Lloyd’s (“Underwriters”) will be providing the financial service. Keystone is authorised to quote, bind and issue Certificates of Insurance under a Binding Authority Agreement (Binder) granted to Keystone by those Underwriters. Keystone will provide details of the syndicate numbers and the proportions underwritten by them on request.

General Insurance Code of Practice

Lloyd’s supports the General Insurance Code of Practice and its purpose of raising the standards of practice and service in the general insurance industry.

What is the Product Disclosure Statement?

The Product Disclosure Statement (PDS) contains information about this Policy including the benefits and conditions, information needed to assist in making an informed decision when choosing insurance, and the rights provided to the entity or person once covered by the insurance. In this PDS:

(a)	Keystone means Keystone Underwriting Australia Pty Ltd.

(b)	Insured means the entity that will be named in the Schedule as the Insured. The type of cover chosen will be set out on this Policy’s Schedule.

Updating the PDS

Information in this PDS may need to be updated from time to time. A copy of any updated information can be obtained without charge by contacting Keystone on the details provided in this Policy. Keystone will provide the Insured with a new PDS or a supplementary PDS if the update is to correct a misleading or deceptive statement or an omission that is materially adverse from the point of view of a reasonable person deciding whether to acquire this Policy.

What makes up the Insurance Contract?

This contract of insurance is made up of the Schedule, this Policy and any Endorsements that Keystone issues when an application is accepted or an existing Policy is renewed or amended.

Significant Features, Benefits and Exclusions

This Policy provides many significant features and benefits, subject to Conditions and Exclusions. Exclusions apply to this Policy and all of them are important. It is important that this Policy is read carefully to be aware of and understand the extent of cover that it offers. It will give full details of the Exclusions.

Significant Risks

The Insured should make sure that the sum insured and the limits to be purchased will be sufficient. All the terms and conditions contained in this Policy need to be understood.

Doctrine of Utmost Good Faith

Every insurance contract is subject to this doctrine which requires the parties to the contract to act toward each other with the utmost good faith. Failure to do so may prejudice any claims and/or the continuation of the insurance contract.

The Insured’s Duty to Not Make a Misrepresentation - (this applies to consumer insurance contracts only)

The Insured has a duty under the Insurance Contracts Act 1984 (ICA) to take reasonable care not to make a misrepresentation to Keystone (the Insured’s duty). The Insured’s duty applies only in respect of a policy that is a consumer insurance contract, which is a term defined in the ICA.

The Insured’s duty applies before the Insured enters the policy, and before the Insured renews, extends, varies, or reinstates the policy.

The Insured may be asked questions, answers to which Keystone will use to decide whether to insure the Insured and anyone else to be insured under the policy, and on what terms. The Insured’s answers to the questions must be truthful, accurate and complete to ensure the Insured meets the Insured’s duty.

If the Insured does not meet the Insured’s Duty

Keystone may:

- be able to cancel the Insured’s contract, or

- reduce the amount to be paid to the Insured if the Insured makes a claim, or

- both the above.

Keystone may be able to refuse to pay a claim and treat the contract as if it never existed if the Insured’s failure is fraudulent.

Change of Circumstances

The terms and conditions of this Policy will be based on information the Insured provided to Keystone. It is essential Keystone are advised of any material change that occurs to this information prior to the inception of this Policy. Failure to do so by the Insured may prejudice any subsequent claims under the Policy and/or jeopardise the continuation of the insurance contract.

Buying Insurance

Set out below are important matters that apply to the initial enquiry, buying of insurance, and renewal of cover. Defined terms are the same as in the Policy.

Keystone’s Agreement with the Insured

Keystone will cover Employees for:

(a)	Injury because of one or more of the Insured Events, and

(b)	the other benefits, as set out in this Policy occurring during the Period of Insurance.

Cover will be given on the basis:

(a)	that the Insured have paid or agreed to pay Keystone the premium for the cover selected when the Insured applied for cover and which the current Schedule indicates is in force; and

(b)	of the verbal and/or written information provided by the Insured which was given after having been advised of the Duty of Disclosure either verbally or in writing. Keystone may be entitled to reduce liability under this Policy in respect of a claim or Keystone may cancel the Policy if the Insured failed to comply with the Duty of Disclosure. Keystone also have the option of voiding this Policy from the effective date stated in the Schedule if the Insured has told Keystone something which is fraudulent. Keystone have provided a full explanation of the Duty of Disclosure and the consequences of Non-Disclosure on page 3.

Journey Accident

Keystone will pay the Employee the benefit set out in the Schedule and Table of Benefits if the Employee suffers an Injury resulting from an accident during the currency of this Policy. The Injury suffered must:

(a)	be one of the type set out in the Table of Benefits in this Policy; and

(b)	arise within twelve (12) calendar months from the date of the Accident.

Keystone will cover the Employee against Injury for:

(a)	defined events 1-18 in the Table of Benefits; or

(b)	a weekly accident benefit (temporary disablement events 19 and 20) in the Table of Benefits; or

(c)	broken bones event 21 in the Table of Benefits.

This Policy has some Extensions. These are fully explained in this Policy, but are as follows:

(a)	disappearance; or

(b)	exposure; or

(c)	funeral expense; or

(d)	home/car modifications; or

(e)	non-Medicare medical expenses; or

(f)	pharmaceutical expenses.

The Period of Insurance will be set out in this Policy’s Schedule.

Exclusions

Keystone will not pay benefits arising from certain causes. These are fully explained in this Policy, but are as follows:

(a)	air travel; or

(b)	alcohol; or

(c)	criminal acts; or

(d)	drugs; or

(e)	mental illness/mental disorders/emotional disorders; or

(f)	pre-existing conditions; or

(g)	radioactivity; or

(h)	suicide/intentional self-injury/insanity; or

(i)	terrorism; or

(j)	war.

Keystone will not make any payments that would be in contravention of any sanction, prohibition or restriction.

Information that Keystone ask

Keystone will only ask for and consider relevant information when assessing the Insured’s application for cover.

Assessing Applications

The Insured will have access to information that Keystone has relied on in assessing their application and an opportunity to correct any mistakes or inaccuracies. Keystone may decline to release information in special circumstances, but will not do so unreasonably. Keystone will give reasons in these circumstances, and the Insured will have the right to request Keystone to review the decision through Keystone’s complaints handling procedures. Keystone will provide reasons in writing upon request.

Mistakes

Keystone will immediately initiate action to correct an error or mistake in assessing the Insured’s application for cover where it is identified.

Misrepresentation

Keystone’s sales process will be conducted in a fair, honest and transparent manner.

Declining Cover

If Keystone cannot provide insurance cover, Keystone will:

(a)	give reasons; and

(b)	refer the entity/person seeking insurance to another insurer, ACFA or NIBA, for information about alternative insurance options (unless they already have someone acting on their behalf).

Keystone will make available information about Keystone’s complaints handling procedures if the entity/person is unhappy with Keystone’s decision.

Policy Information

Information about Keystone’s policy wordings will be available when the Insured buy insurance from Keystone as well as on request. They will also be available on Keystone’s website at www.keystoneunderwriting.com.au.

Subrogation

The Insured may prejudice their rights regarding a claim if, without prior approval from Keystone, the Insured makes an agreement with a third party that would prevent Keystone from recovering any applicable loss (in whole or in part) from that, or another party.

This Policy contains provisions that have the effect of excluding or limiting Keystone’s liability for a claim under this Policy if you have entered into any agreement that excludes, limits or delays the Insured’s right to recover damages from another party in respect of such claim.

Cost of Policy

The cost of this Policy is made up of premium plus any applicable policy fees, government taxes and charges. Keystone may cancel this Policy if the Insured fails to pay the total premium due.

Deductibles

The Insured may be required to pay a deductible or excess if a claim is made under this Policy. Details of applicable deductibles or excess are provided in the Schedule. This Policy sets out the terms relating to the payment of deductibles or excesses.

Taxation

All taxes and charges are shown as separate items (e.g. fire and emergency services levy, stamp duty depending upon location and GST).

Cooling-off Period

The Insured has the right to cancel this Policy with Keystone within 14 days of the date that the Policy incepted, unless a claim is made. Keystone will refund the full amount of the premium less any duties or taxes payable if this cancellation occurs during the cooling-off period. This Policy will be terminated from the date Keystone receive the request to cancel.

Making a Claim

Benefits are payable if the Employee suffers a loss that is covered under this Policy during the Period of Insurance, except if an Exclusion or Condition applies. The Insured must immediately notify Keystone or their insurance adviser if there is a loss under this Policy.

The Employee needs to see a qualified medical practitioner as soon as possible after the Injury as benefits will only be paid from the date medical attention is first sought.

Keystone may at any time after a claim has been lodged:

(a)	request the Employee undergo medical or related examinations. Keystone may require an autopsy in the event of death;

(b)	conduct enquiries into the circumstances of the claim;

(c)	request the Employee’s attending doctor or specialist to provide a progress report.

This will be at Keystone’s expense.

Any payments under this Policy will be to the Employee or, in the event of the Employee’s death, the Employee’s legal representative.

Taxation Implications

A claim paid in respect of weekly disability benefits is subject to personal income tax and it is the Employee’s responsibility to declare such benefit when completing the Employee’s usual tax return. It is up to the Employee to seek advice of a tax consultant if there are any questions about their own circumstances.

Advisers’ Remuneration

Keystone pay remuneration to insurance advisers when Keystone issue, renew or vary a Policy that the adviser has arranged or referred to Keystone. The type and amount of remuneration varies and may include commission and other payments. The Insured should ask their advisers if more information about remuneration Keystone may pay them is required.

Renewal Procedure

Keystone will normally offer renewal by sending a renewal invitation advising the amount payable to renew this Policy before this Policy expires. It is important that the Insured check the information shown before renewing each year to be satisfied that the details are correct.

Cancelling the Policy Before the Due Date

The Insured may cancel this Policy at any time by notifying us in writing, detailing the date that the cancellation will take effect. Keystone will refund any unearned premium to the Insured or their insurance adviser within 15 working days after the date of cancellation. Unearned premium will be computed pro rata for the unexpired term of this Policy, unless agreed in advance through the insurance adviser and set out in this Policy.

Privacy

Keystone are committed to safeguarding and protecting the Insured’s privacy. Keystone is bound by the provisions of the Privacy Act 1988 which sets out the standards to meet in the collection, use and disclosure of personal information.

The Act defines “personal information” as “information or an opinion about an individual whose identity is apparent or can reasonably be ascertained from the information or opinion”.

Purpose of Collection

Keystone will only use personal information the Insured provides to quote on and insure risks and matters incidental thereto, including investigating and managing claims.

It may be necessary for Keystone to provide the Insured’s personal information to others, such as other insurers or reinsurers, claims investigators, lawyers and other professionals, and government bodies. Keystone will not under any circumstances trade, rent or sell the information.

Keystone cannot properly quote insurance and cannot insure the Insured if they do not provide Keystone with complete, accurate and up-to-date information. If the Insured provide Keystone with personal information about anyone else, Keystone will rely on the Insured to have told them that their information will be provided to Keystone, to whom Keystone may provide it, the purposes for which Keystone will use it and that they can access it. Keystone relies on the Insured to have obtained their consent on these matters if the information is sensitive.

Access to Information

The Insured can check the personal information Keystone holds about them at any time. Requests for access can be made in writing to:

The Privacy Officer

Keystone Underwriting Australia Pty Ltd

17/296 Bay Road

Cheltenham, VIC 3192

Keystone will keep the Insured informed of any delays in responding to the Insured’s request throughout the process.

General Insurance Code of Practice

The Insurance Council of Australia Limited has developed the General Insurance Code of Practice (“the Code”), which is a voluntary self-regulatory code. The Code aims to raise the standards of practice and service in the insurance industry.

Lloyd’s has adopted the Code on terms agreed with the Insurance Council of Australia. For further information on the Code please visit www.codeofpractice.com.au.

The Code Governance Committee (CGC) is an independent body that monitors and enforces insurers’ compliance with the Code. For more information on the Code Governance Committee (CGC) go to www.insurancecode.org.au.

Complaints and Disputes

If you have any concerns or wish to make a complaint in relation to this policy, our services or your insurance claim, please let us know and we will attempt to resolve your concerns in accordance with our Internal Dispute Resolution procedure. Please contact Keystone Underwriting Australia Pty Ltd in the first instance:

The Complaints Officer

Keystone Underwriting Australia Pty Ltd

17/296 Bay Road

Cheltenham, VIC 3192

Phone: 1300 946 530

Email: complaints@ksua.com.au

We will acknowledge receipt of your complaint and do our utmost to resolve the complaint to your satisfaction within 10 business days.

If we cannot resolve your complaint to your satisfaction, we will escalate your matter to Lloyd’s Australia who will determine whether it will be reviewed by their office or the Lloyd’s UK Complaints team. Lloyd’s contact details are:

Lloyd’s Australia Limited

Email: idraustralia@lloyds.com

Telephone: (02) 8298 0783

Post: Suite 1603 Level 16, 1 Macquarie Place, Sydney NSW 2000

A final decision will be provided to you within 30 calendar days of the date on which you first made the complaint unless certain exceptions apply.

You may refer your complaint to the Australian Financial Complaints Authority (AFCA), if your complaint is not resolved to your satisfaction within 30 calendar days of the date on which you first made the complaint or at any time. AFCA can be contacted as follows:

Telephone: 1800 931 678

Email: info@afca.org.au

Post: GPO Box 3 Melbourne VIC 3001

Website: www.afca.org.au

Your complaint must be referred to AFCA within 2 years of the final decision, unless AFCA considers special circumstances apply. If your complaint is not eligible for consideration by AFCA, you may be referred to the Financial Ombudsman Service (UK) or you can seek independent legal advice. You can also access any other external dispute resolution or other options that may be available to you.

The Underwriters accepting this Insurance agree that:

(i)	if a dispute arises under this Insurance, this Insurance will be subject to Australian law and practice and the Underwriters will submit to the jurisdiction of any competent Court in the Commonwealth of Australia;

(ii)	any summons notice or process to be served upon the Underwriters may be served upon:

Lloyd’s Underwriters’ General Representative in Australia

Suite 1603

Level 16

1 Macquarie Place

Sydney NSW 2000

who has authority to accept service on the Underwriters’ behalf;

(iii)	if a suit is instituted against any of the Underwriters, all Underwriters participating in this Insurance will abide by the final decision of such Court or any competent Appellate Court.

In the event of a claim arising under this Insurance immediate notice should be given to:

Claims Department - Keystone Underwriting Australia Pty Ltd

Telephone: 1300 946 530

Email: claims@ksua.com.au