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. *

When did the business start (year)?

Occupation

Please give a full description of your occupation.
By giving a full description the insurer gets an understanding of what you do and can then favourably rate your premium.

Quote Required

Please nominate the amount of cover you require:

Public Liability

Not required

$5,000,000

$10,000,000

$20,000,000

Underwriting questions

Number of employees (include principals)

Number of labour hire, contract labourers:

Estimated turnover of the business per year $

What percentage of turnover is heat work away from your premises?
  %
(ie welding or hot cutting activities)

Contractors

Do you employ contractors or sub-contractors?
Yes    No

If YES,

What percentage of turnover is generated from sub-contractors?
  %

Do they have their own Public Liability cover?
Yes    No

Do you require cover for sub-contractors?
Yes    No

Insured's History

The questions below relate to the insured, or any partner or director or any other person responsible for managing the business. They also relate to any other business in which the insured or partners/directors have been trading. Have any of the above:-

• Ever been convicted (or charged but not tried) with any criminal offence, or
• Ever been declared bankrupt or insolvent or gone into liquidation or receivership,or
• Had any insurance policy cancelled or declined by an insurer, or
• Been prosecuted under any health and safety legislation or similar laws in the past 5years?

Declaration

By submitting this Declaration, the Applicant declares that:

• the contents of this Declaration are true and complete,
• I/we have read the information concerning the duty of disclosure (immediately below this declaration) and other important notices;
• I/we have answered every question fully and frankly, have been truthful and accurate in completing this application and have not withheld any information likely to affect the acceptance of this insurance;
• I/we realise that if I/we have not complied with the duty of disclosure, any claims may not be met
• if anything happens during the Period of Cover which alters any of the information provided, I/we will promptly inform the insurer;

Name of person making this declaration:

Duty of Disclosure (What you must tell us)
Under the Insurance Contracts Act 1984 (the Act), you have a Duty of Disclosure. You are required before you enter into, renew, vary, extend or reinstate your Policy, to tell us everything you know and that a reasonable person in the circumstances could be expected to know, is a matter that is relevant to our decision whether to insure you, and anyone else to be insured under the Policy, and if so, on what terms.

You do not have to tell us about any matter:

• that diminishes the risk
• that is of common knowledge
• that we know or should know in the ordinary course of our business as an insurer, or
• which we indicate we do not want to know.
• If you do not tell us