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:

Insured Name

ABN No. (if known)

Full Address

Email Address

Phone No.

Start date of business (year):

Trade Duties

What is your occupation (eg.bricklayer):

Please provide full description of Your business activities.

Cover Required

Please nominate the amount of cover you require:
Limit of indemnity:
$5,000,000
$10,000,000
$20,000,000

Underwriting Questions

Number of full time employees:

Number of part time employees:

Estimated turnover per year:

Does the business:

Undertake work on large industrial sites?
Yes    No

Undertake welding or hot cutting activities away from own premises?
Yes    No

Perform work at mine sites, either above or below ground?
Yes    No

Provide products or services intended for use in the mining industry?
Yes    No

Provide equipment on hire?
Yes    No

Import any products into Australia?

Yes    No

Export any products to the USA or Canada?

Yes    No

Is the business involved in any of the following activites?
- Wharf or any form of ship handling or loading facility
- Aircraft, Airports, Airlines, Satellites, Space or Radar Installations
- Public Utilities (eg Power Plants, Water Treatment, Communication)
- Military Installations
- Dams
- High voltage power supply
- Railways
- Chemical Manufacturers
- Oil and/or Gas Production
Yes    No

Contractors

Do you employ contractors or sub-contractors?
Yes    No

Labour Hire

Do you engage personnel provided through labour hire companies?
Yes    No

WARNING: Signing of Contracts
There are potential insurance ramifications of signing contracts without appropriate legal advice. Many contracts have clauses that put the insured in a situation where they may not be covered under their liability policies. Policies usually have an exclusion relating to Contractual Liability. Basically, the exclusion states that the Insurer will only provide indemnity for any contractual liability where the signing of the contract does not increase the insured's liability beyond what would have applied had the contract not been signed.

Workcover / Workers Compensation
Workers Compensation insurance is compulsory for all employees. You need to be very careful about what the definition of an employee is and this can vary from state to state. If you have no cover in place, then you should arrange cover immediately.
NOTE: We do not handle Workcover insurance but we can point you in the right direction if you need to arrange cover.
Sub-Contractors - If you are not operating under a company structure and you hire sub-contractors that are not working under a company structure, then it is likely that you will be held responsible for any injuries that a sub-contractor incurs whilst performing work for your business. The fact that they may have their own ABN and submit invoices for their work is unlikely to get you off payment of their injuries

Your History

Have you or anyone to be insured under this policy:

• Had insurance cancelled or declined by an Insurer?
• Had a 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 declared bankrupt or insolvent?
• Been liable for any civil offence or pecuniary penalty?
• Been charged or convicted for any criminal offence?
• Been charged or convicted for fraud, theft or dishonesty?

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.

Name of person making this declaration: