Medical Provider Network Application

- Self Assessment Questionnaire -

All questions must be answered by every Medical Provider (referred to as “company”).

Name of Company: ___________________________________________________________

Name of Company Contact: ____________________________________________________

Name of Allianz Partners Contact: _______________________________________________

Date: ______________________________________________________________________

A. Company Information
1. In which country is

a) the company, or
b) the potential contractual party (if different from the company) registered?

Please provide evidence of incorporation within the above noted country along with valid
Medical License within the country.

2. Is your company or any company in the chain of command up to your ultimate beneficiary
owner listed at a stock exchange?

Yes ☐ No ☐

If Yes, at which stock exchange(s)?

☐ NYSE
☐ German Stock Exchange
☐ Other (please specify): _________________________

3. Does your company have

a) an Anti-Corruption Policy

b) other anti-corruption standards as part of a global anti-corruption program in

place (e.g., gifts & entertainment guidelines)?
Yes ☐ No ☐

If yes, please attach details or indicate where relevant information can be found on your
homepage.

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4. Have there been charges/fines within the last 36 months for any violation of any bribery and
corruption law, or are there current investigations by a law enforcement/custom agency/tax
authority or any central/regional/local government authority for potential violation of any
bribery and corruption laws for the following:
a) your company

b) any company in the chain of command up to your ultimate beneficiary owner

c) any of a)’s or b)’s officers, directors or managing partners
(as part of their duties in relation to the company)

Yes ☐ No ☐

If Yes, please provide details of the case(s) and subsequent mitigation efforts in a transparent
manner.

Are the cases closed? Yes ☐ No ☐

5. Is your Company Registered with your local Data Protection Authority/Information

Commissioner as a Data Controller or do you have a registered Data Protection Officer?

Yes ☐ No ☐

If yes, please provide evidence of registration.

6. Are any of your company's officers, directors, managing partners or any directly involved
employees related and/or closely associated with an employee of Allianz Partners?

Yes ☐ No ☐

If, Yes, please provide further details.

7. Does your company hold and maintain Professional Indemnity Insurance (Including Medical
Professional Liability Insurance) to a level sufficient to cover local market requirements or the
activity they are looking to perform for Allianz Partners (Whichever the greater)?
Yes ☐ No ☐

If Yes, Please provide evidence of coverage (i.e. Insurance Certificates).

B. Interaction with Government Officials

Definition Government Official:
Government Official includes anyone work ing in an official capacity for or on behalf of government-
owned or controlled entities or agencies, political parties, party officials, and political candidates, or
for a public international organization with government members (for example, World Bank). This
may include consultants who hold government positions, employees of companies owned or
controlled by governments, political party officials and others, or employees retained by government
agencies. This term also covers local and foreign government officials and immediate family
members (parent, spouse, child, in-law, sibling), and anyone else to whom the Government Official
provides material support.

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8. Will your company as part of the performance of the upcoming contract with Allianz Partners be
in direct contact with a Government Official, e.g., to obtain licenses?

Yes ☐ No ☐

If Yes, please provide details:

9. Are any of your company's officers, directors, managing partners or any directly involved
employees a Government Official himself?

Yes ☐ No ☐

If Yes, please provide details:

C. Subcontractors/Consortia
10. Do you plan to use subcontractors?

Yes ☐ No ☐

If Yes, please confirm that you do not have any doubts on the subcontractor’s integrity:

Confirm ☐ Cannot Confirm ☐

11. For the potential agreement with Allianz Partners, do you act as the representative of a
consortium?

Yes ☐ No ☐

If Yes, please confirm that you do not have any doubts on the integrity of the members of the
consortium:

Confirm ☐ Cannot Confirm ☐

D. Labour Hire Licensing

12. As a part of your services to Allianz Partners, will your company/business supply any workers
to do work?

Yes ☐ No ☐

If Yes, in which State(s)/Territory(ies) will the work be performed:

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 If Yes, please provide your labour hire licence number(s) and the relevant
State(s)/Territory(ies):

If Yes and your company/business does not hold a labour hire licence(s), please explain why
(e.g. you have obtained confirmation that an exemption under the Regulations applies):

E. Supplier Code of Conduct

13. Your Company agrees to comply with the Allianz Group Supplier Code of Conduct:
https://www.allianz.com/content/dam/onemarketing/azcom/Allianz_com/responsibility/document
s/allianz_code_of_conduct.pdf

AGREE: 
DISAGREE: 

F. Compliance with Modern Slavery Legislation

14. As a condition of engaging in a services agreement with Allianz Partners, you must
acknowledge that following:

Allianz Partners is actively taking steps to mitigate the potential risk of Modern Slavery
within our business and supply chains. Modern Slavery includes slavery, servitude, debt
bondage, forced and compulsory labour, the worst forms of child labour, organ trafficking
and human trafficking.

Allianz Partners has committed to and expects partnered companies to commit to the following:

a) Act ethically and with integrity in all business dealings and relationships;

AGREE: 
DISAGREE: 

b) Implement and enforce effective systems and controls with a view to ensuring
that its business and supply chains are free from modern slavery and human
rights abuses;

AGREE: 
DISAGREE: 

c) Ensure there is transparency in its business and approach to tacking Modern
Slavery consistent with its reporting obligations under applicable local legislation;

AGREE: 
DISAGREE: 

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15. To the best of your knowledge, your company operations and supply chains do not involve
the use of any modern slavery;

CONFIRM: 
CANNOT CONFIRM: 

You will immediately inform Allianz Partners if you become aware of any actual or suspected
modern slavery within your operations or supply chains;

AGREE: 
DISAGREE: 


Signed____________________________________________

Print Name_________________________________________

Date ____________________________________________

Company Stamp:

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