Step 1.
Select Level of Cover $1,000,000 $2,000,000 $5,000,000 $10,000,000
Step 2. (Optional)
Include Public Liability $10,000,000 +($300) or Include Public Liability $20,000,000 +($420)
Cardholders Name
Credit Card No.
Select Expiration Date: 01 02 03 04 05 06 07 08 09 10 11 12 19 20 21 22 23
Cover will be placed and a Tax Invoice will be emailed to you.
Note: A Certicate of Currency cannot be issued until payment is made.
When do you want cover to start?
Processing is only done through business hours. Cover is not in place until this form is received and accepted by our office. We will then email you a tax invoice. NOTE: A "Certificate of Currency" will not be sent until payment is made.
Insured Name
Trading Name
ABN No.(if known)
Full Address
Email Address
Website Address
Phone No. *
Start date of business:
What is your occupation (eg.management consultant):
Are you involved in corporate consulting to large Public Companies? Yes No
Do you hold the necessary qualifications to perform these tasks? Yes No
Do you provide advice or services in any of the following areas:
No. of people in the business
Gross Revenue - last year If Nil, put in "0"
Australia
USA/Canada
Overseas
Estimated for next year If Nil, put in "0"
Please state the percentage of Your activities (based on income) for each State
Do you employ contractors, sub-contractors? Yes No
Does your occupation involve:
Have any claims been made against You or Your business or any prior business or has any fact or circumstance been notified to insurers that has the potential to give rise to such a claim? Yes No
Is anyone in the business aware of any CIRCUMSTANCES which may give rise to a claim against this business? Yes No
Have you (or any person receiving cover under this policy) ever:
By submitting this Declaration, the Applicant acknowledges:
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
If you do not comply with your Duty of Disclosure we may reduce or refuse to pay a claim or cancel your Policy. If your non-disclosure is fraudulent we may treat this Policy as never having worked.
Claims Made Policy This declaration is for a claims made and notified Policy of insurance. This means that the Policy covers you for claims made against you and notified to the insurer during the period of cover. This Policy does not provide cover in relation to: