Public Liability Insurance Consultants

 

Because you have answered the previous question with a "YES", we need to get a proposal form completed before we can get a quote.

If you need advice, please call Liability Brokers: 1300 881 779

To proceed, please complete the following form.

If you have spoken to a broker in our office, note their name here so that this quote can be processed by them as they will know something about you already.

Brokers Name:

Client Details

Insured Name

Trading Name

ABN No.(if known)

Full Address

Email Address

Website Address

Phone No. *

 

Professional Duties

What is your occupation:

Please provide details of what your occupation entails:

 

Manual Risk Exposure

Does your occupation involve manual risk exposure?
ie. does your occupation involve:

  • Manual labour or manual tasks performed by yourself (apart from measuring)
  • The supervision of manual labour or manual tasks performed by other parties
  • The responsibility of manual labour or manual tasks performed by other parties
  • The training of others on how to perform manual tasks
Yes    No

 

Underwriting questions

Please nominate the amount of cover you require:

Public Liability:

Number of employees (including principals)

Estimated fees (per year)

 

Contractors

Do you employ contractors, sub-contractors?
Yes    No

 

High Risk areas

Do you provide services in any of the following areas:

  • Aerospace, Aircraft or Radar Insatallations
  • Electricity Generation or Distribution
  • Military Installations
  • Oil Reineries or Nuclear Installations
  • Mining Sites
Yes    No

 

Professional Indemnity

Do you provide any advice, design or professional service (other than instructions or warnings provided with a product), whether or not you charge for such advice, design or professional service.
Yes    No

If the answer is "Yes", you should apply for Professional Indemnity Insurance.

Do you want us to send you a form for Professional Indemnity Form?
Yes    No

 

Insured's History

Have you (or any person receiving cover under this policy) ever:

  • Had insurance cancelled or declined by an Insurer?
  • Had a proposal rejected, renewal refused or claim rejected by an Insurer?
  • Had any special conditions imposed?
  • Suffered a loss whether insured or not (last 5 years only)?
  • Been involved in a company that has declared bankruptcy or became insolvent?
  • Been liable for any civil offence or pecuniary penalty (exceeding $5,000)?
  • Been charged or convicted for actual or threatened damage to property?
  • Been charged or convicted for fraud, theft or dishonesty of any kind?
  • Been charged or convicted for drugs or any OTHER criminal offence?
Yes    No


Type the above number:



Declaration

By submitting this Declaration, the Applicant acknowledges:

  • they are authorised by each of the other Applicants to make this Declaration,
  • the contents of the Declaration are true and complete,
  • they are under a continuing obligation to immediately inform the Insurer of any change in the particulars or statements contained in this Declaration or in the accompanying documents up until the contract is entered into,
  • they authorise the Insurer to give or obtain from other insurers or insurance reference bureaus or credit reporting agencies, any information about this insurance or any other insurance held by the Applicant/s.
  • that no cover is in place until this form is accepted by the insurer

Name of person making this declaration: