High Street Underwriting Agency - PI Mining Proposal 0512 1

P | 1800 096 829F | 1800 096 680

A.F.S Licence 244370 A.C.N 096 939 169

1. How to Complete This Form

2. Your Duty of Disclosure

Your duty however does not require disclosure of a matter:

• that diminishes the risk to be undertaken by the insurers;

• that is common knowledge;

• that the insurers know or, in the ordinary course of business as insurers, ought to know; or

• as to which compliance with your duty is waived by the insurers.

3. Non-Disclosure

This Proposal Form must be typed, or completed in ink and signed and dated by the Proposer: Please answer every question fully, and state “NIL” or “NONE” as applicable. Incomplete answers may not be accepted and can delay quotation.

If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce their liability under the contract in respect of a claim. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning.

Should there be insufficient room in the Proposal Form for full details, please use the additional information section at the end of the Proposal. Please also attach any supporting information which you feel may assist us in understanding your professional business practice

Before you enter into a contact of general insurance with any insurer, you have a duty, under the Insurance Contracts Act 1984, to disclose to the insurer every matter you know or could reasonably be expected to know to be a matter relevant to the decision of the insurer whether to accept the risk and, if so, on what terms.

You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of insurance.

The requirement of full and frank disclosure of anything which may be material to the risk for which you seek cover (for example, claims, whether founded or unfounded), is of the utmost importance with this type of insurance.

If you do not understand any part of this Proposal Form, seek advice from your professional insurance adviser, as you will be bound by your answers and any the information provided by you.

PROPOSAL FORM Professional Indemnity Insurance

IMPORTANT NOTICE

FORContractors working on mine sites and

associated activities

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4. Claims Made & Notified Insurance

The policy does not cover your civil liability for breach of professional duty arising from any claim:

• first made prior to the inception of the Policy;

•

•

5. Retroactive Date

6. Subrogation

7. Change in Risk or Circumstances

8. Privacy

9. Completeness of Answers

Copies of the Proposal Forms should be retained for your records.

This insurance is written on a “claims made and notified” basis. This means that the insurer indemnifies you for Claims (as defined) that are made against you during the period of insurance and notified to the Insurer during the period of insurance. The policy does not provide cover for any claims made against you during the period of insurance if at any time prior to commencement to the period of insurance you became aware of facts which might give rise to those Claims being made against you.

Section 40(3) of the Insurance Contracts Act 1984 provides that where you gave notice in writing to the insurer of any facts that might give rise to a Claim against you as soon as reasonably practical after you become aware of those facts, but before the expiry of the period of insurance, the insurer cannot refuse to pay a Claim which arises out of those facts, when made, because it was made after the period of insurance had expired.

directly or indirectly based upon, or attributable to , or in consequence of, any incident, occurrence, fact or matter which you knew or ought or should have reasonably known, had the potential to give rise to a claim under the Policy; or

directly or indirectly based upon, or attributable to, or in consequence of any fact, matter, circumstance or occurrence which has been notified under any other insurance attaching prior to the inception date of the Policy.

The proposed insurance may be limited by a retroactive date. If so, the policy will not cover any claims or circumstances arising from any events, omissions or conduct prior to such retroactive date.

Where you have prejudiced the insurers rights to recover a loss from another party, this may have the effect of excluding or limiting the insurers liability in respect of that loss.

You should advise the insurer(s) as soon as practicable of any material change in your business activities (as disclosed in the Proposal Form).

New privacy legislation took effect on 21st December 2001. The legislation regulates the way private sector organizations can collect, use, keep, secure and disclose personal information. We have developed a privacy policy that explains what sort or personal information we hold about you and what we do with that information. Please refer to our website for a copy of our Privacy Statement.

ANSWER ALL QUESTIONS TO THE BEST OF YOUR KNOWLEDGE AND BELIEF. DO NOT LEAVE ANY QUESTIONS UNANSWERED.

ALL MATERIAL FACTS MUST BE DISCLOSED, AS FAILURE TO DO SO MAY NULLIFY ANY POLICY OR CERTIFICATE ISSUED.

IF YOU CONSIDER THAT ANY QUESTION REQUIRES KNOWLEDGE WHICH YOU ARE UNABLE TO PROVIDE, INDICATE THIS IN YOUR ANSWER OR ASK HIGH STREET UNDERWRITING AGENCY PTY LIMITED FOR ADVICE.

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YOUR DETAILS1. Name

_______________________________________________________ __________________________________________________________________________ __________________________________________________________________________ ___________________2. Contact DetailsBusiness Address:________________________________________________________________________Suburb: State: Postcode:____________________________ ___________________ ___________________________Phone: Fax: Mobile:____________________________ ___________________ ___________________________Email: Website:_____________________ ___________________3. Particulars of all persons giving advice on behalf of the business (please attach CV's)Name Age Qualifications Years Experience_____________________________ ________ ________________________ ________________________________________________ ________ ________________________ ________________________________________________ ________ ________________________ ________________________________________________ ________ ________________________ ________________________________________________ ________ ________________________ ________________________________________________ ________ ________________________ ___________________- If there is not enough space provided, please use the additional information page at the end of this form.

4. Staff NumbersPlease provide total number of:(a) Partners/Directors/Principals: ____________________ (b) Professionally Qualified staff: _____________________(c) Trade qualified (or training) Staff: __________________(d) Other Staff: __________________PERIOD, LIMITS AND EXCESS OF INSURANCE1. Period of Insurance

(a) Insurance cover is needed from:___________to: ________________

2. Insurance Limits

(a) For what Limit/s of Indemnity are quotations required?

$2,000,000

Other - Please specify: ____________________

3. Excess

(a)

$2,500'Other - Please specify: ____________________

Commencement date of business

$5,000,000 $10,000,000

Insured (Full names of all entities requiring cover including trading names):

There will be a minimum level of uninsured excess. Is a quotation required with a voluntary excess to achieve a premium saving? Please select as appropriate:

$10,000$5,000

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BUSINESS PARTICULARS1. Business Description & Other(a)

(b) Do you carry out any underground work? Yes No- If 'Yes', please provide further details below:

(c) Do you provide any reports or is any professional advice given? Yes No- If Yes, please supply sample copy of report given

(d) Is any of the work for which you are responsible subcontracted? Yes No(e) Do you ensure that all subcontractors carry professional indemnity insurance? Yes No(f) Have you entered into a written contract with the mine/s ? Yes No

2. Fee Income Information

(a) Please provide details of professional gross fees received below:

Last Year Current Year(Month/Year) (Month/Year)

Description of Professional Service Provided ______ /______ _____ /______$_____________ $__________$_____________ $__________$_____________ $__________$_____________ $__________

(b) Percentage of work undertaken overseas (Last Year):USA/Canada %__________Elsewhere Overseas %__________

(c) Please provide a percentage split of your FEE income by geographical area:NSW %___________ SA % _____________ ACT % _____________VIC %_____________ WA %_____________ TAS % _____________QLD %____________ NT %_____________ Overseas % _________

3. Claims / Insurance History

(a) Are you currently insured for Professional Indemnity insurance? Yes No- If 'Yes', please advise:

(i) Name of Insurer(s): ________________________(ii) Limit of Indemnity: ________________________(iii) Retroactive Date: _________________________ (iv) Premium (excl GST & Stamp Duty): _________________________(v) Excess: _________________________(vi) Rnewal Date: _____________________

Please provides a full description of your business activities, including any activities undertaken in the last six (6) years not currently undertaken; and any new activities planned in the next 12 months:

____________________________________________________________________________________________________________________________________

____________________________________________

- If yes please enclose a copy of the Insurance section of the contract. Plus any other Section relevant to assessing the risk.

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(b)Yes No

- If 'Yes', please provide further details below:

(c)Yes No

- If 'Yes', please provide further details below:

(d)Yes No

-If Yes, please give details including date and cost/estimated cost of claim/loss:

-If Yes, what steps have been taken to prevent a recurrence?

(e)Yes No

-If Yes, please give details including date and cost/estimated cost of claim/loss:

Has the Firm (or its predecessors or any past or present principal or director) had any insurer decline a proposal, impose special terms or had a similar insurance cancelled or refused to renew?

If an insurance similar to that now proposed has been or is now in effect would any claim which has been made or which is now pending against any persons proposed for insurance fall within the scope of such insurance?

Is any person aware, AFTER ENQUIRY, of any circumstances or incidents which he/she has reason to believe might give rise to any claim against the Firm or any Directors, Officers or Employees of the Firm?

Has any claim for professional negligence, error or omission ever been made against the Firm and or Partners/Directors/Principals or Employees and or their predecessors in the Firm whether insured or not?

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Please return the completed form to your Insurance Broker

For Brokers and Direct Clients only, please return this form to one of our team members below:

P | 1800 096 829F | 1800 096 680 W | www.hsua.com.au & www.miningliabilityinsurance.com.au

Company: ________________________________

Date: ____________________________________

(Please print and sign in pen)

Signing of this Proposal Form does not bind the Proposer or Underwriters to complete a contract of Insurance.

Form Return Details

I have received the Important Notice at the beginning of this Proposal Form and I have read and understood the contents therein; and

I understand that, up until a contract of insurance is entered into, I am under a continuing obligation to immediately inform the Underwriters of any change in the particulars or statements contained in this Proposal Form or accompanying documents; and

I understand that the submission of this Proposal Form does not bind either the Underwriters or the Firm specified above to enter into a binding contract of insurance.

Signed: __________________________________

Capacity: _________________________________

I am authorised to complete this Proposal Form and to accept the quotation terms for this insurance on behalf or the Firm referred to above (including on behalf of its partners, principals and directors); and

All answers to the questions contained in this Proposal Form are, AFTER ENQUIRY, true and correct to the best of my knowledge and belief and that no material facts have been misstated, omitted or suppressed; and

DECLARATION

Sydney Vikram Choudhry vikram@hsua.com.a

Brisbane Alan Whittle alan@hsua.com.au

Perth Arthur Payne arthur@hsua.com.au

Melbourne David Pool david@hsua.com.au

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ANY ADDITIONAL INFORMATION YOU WISH TO PROVIDE