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
Full time  

Number of employees
Part time  

Estimated turnover of the business per year
$  

Do you do welding or hot cutting activities away from own premises?
Yes    No

Do you import or export goods/products?
Yes    No

Does the business:
- Perform work at mine sites, either above or below ground?
- Provide products or services for use in the mining industry?
Yes    No

Do you provide equipment out on hire?
Yes    No

Does Your Business use explosives?
Yes    No

Does Your Business work at heights exceeding 10 metres?
Yes    No

Is your business involved in demolition activities?
Yes    No

Do you provide services or products for use in the following areas?

• Aircraft / Airports / Airlines Radar installations
• Bridge Construction or maintenance
• Chemical Works, Petrochemical Plants
• Dams
• Oil or Gas Production, Pipelines, Offshore platforms
• Public Utilities (ie Power Plants, Water, Communication)
• Railways
• Shipping / Port Authorities
• Watercraft or Marine Vessels

Contractors

Do you employ contractors, sub-contractors?
Yes    No

If YES,

Do they have their own Public Liability cover?
Yes    No

Do they have their own Workers Compensation cover?
Yes    No

Labour Hire

Do you use labour from labour hire companies?
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 declared bankrupt or insolvent or involved in a company that has declared bankruptcy or insolvency?
• Been charged or convicted for a criminal offence?

Declaration

By submitting this Declaration, the Applicant declares that:

• I/we have the consent of all other persons covered by this policy to make this Declaration,
• 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;
• 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:

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