T: 07 3387 1900 | F: 07 3807 1311 | E: [email protected] | W: ajg.com.au PO Box 404, Beenleigh, QLD, 4207 Proposed Moral Hazard Question Set and Declaration Directors’ and Owners’ details Please provide the following details for all Directors and Owners of the proposed insured entities: Full name (including any previous names) Date of birth Address Disclosure Please have each of the above Directors and Owners complete and sign the following declaration: Have you have had any criminal convictions in the past 10 years? Yes No If Yes please provide details: Are you or have you ever been a member of an Outlaw Motor Cycle Club? Yes No If Yes please provide details: Are any of your family members of an Outlaw Motor Cycle Club? Yes No If Yes please provide details: Are you or have you ever been declared a bankrupt? Yes No If Yes please provide details: Definitions Director – As defined under the Corporations Act 2001 Owner – A natural person who has either a shareholding or financial interest in the proposed insured entities Outlaw Motor Cycle Club – Any of the following named clubs and/or clubs that are prescribed by various government bodies, State and Federal to be defined as Outlaw Motor Cycle Clubs. Bandidos Decendants Foolish Few Hells Angels Iron Horsemen Notorious Rebels Satan’s Soldiers Black Uhlans Derelicts Fourth Reich Highway 61 Life and Death Odin’s Warriors Red Devils Satudarah Bros Devil’s Henchmen Gladiators Highwaymen Lone Wolf Outcasts Renegades Tramps (Wangaratta) Club Deroes Diablos (Bandidos) Gods Garbage Huns Mongols Outlaws Rock Machine Vigilanties Coffin Cheaters Finks Gypsy Joker Immortals Nomads Phoenix Satan’s Riders Vikings Comanchero Name: Date: Signature: Arthur J. Gallagher & Co (Aus) Limited. Operates under AFSL No. 238312. Any advice provided in this document does not consider your objectives, financial situation or needs. You should consider if the insurance is suitable for you and read the Product Disclosure Statement (PDS) and Financial Services Guide (FSG) before buying the insurance. If you purchase this insurance, we may charge you a fee for our service to you. Ask us for more details before we provide you with any services on this product. PDS available on request. Our FSG is available on our website, www.ajg.com.au. Arthur J. Gallagher & Co (Aus) Limited. ABN 34 005 543 920, Level 12, 80 Pacific Highway, North Sydney, NSW 2060. REF001911-FEB18.