Tradie Insurance Pack Form 1 Insured Details 2 Covers & General Business Liability 3 Insurance Claims & Declaration Introduction Please answer all questions in this proposal form. Blanks and/or dashes, or answers “known to underwriters or brokers” or “N/A” are not acceptable and will delay processing of this application. If there is insufficient room to complete a question, please attach a signed & dated addendum. Any documents attached to this document form part of this application. Where appropriate, please tick the yes or no box which best indicates your reply. If you have any questions whilst completing this insurance proposal form, please let us know. Thank you. Primary Contact First Name Last Name Job Title / Position Email Phone Mobile Primary Insured Insured Name If you are a sole trader, your name can be added here. Partnerships should list all partners’ full legal names. Companies should list the Pty Ltd entity. For trusts, list both the trust and trustee. Trading Name(s) Your company’s trading name if you have a registered Trading Name. Address Address 2 City State —Please choose an option—ACTNSWNTQLDSATASVICWA Postcode ABN Year Business Established Exempt from Stamp Duty? NoYes If yes, what is your exemption number? What is your Business Website Address? Additional Insureds Are there any other entities or individuals to be insured under this policy? NoYes Additional Insured 1 Insured Name Trading Name(s) ABN Year Business Established Registered for GST? NoYes Input Tax Credit (ITC) % Additional Insured 2 Insured Name Trading Name(s) ABN Year Business Established Registered for GST? NoYes Input Tax Credit (ITC) % Business Details What type of Trade(s) or services do you offer? Estimated turnover for the next 12 months (AUD) Estimated wages for the next 12 months (AUD) Number of full time employees Number of part time employees Directors and Owners count as 1 each. Interested Parties Please list any Interested Parties required to be noted on the policy. If subcontracting to tier-one builders, a principal may ask to be named. Banks or landlords may also need to be noted. Please list names exactly as they should show on quotes and the policy schedule. Current Cover Do you currently have a Trade Pack or a Business Pack insurance cover in place? NoYes Please provide the following details of your current policy: Name of Insurer Policy Limits Excesses Expiry Date of Policy After a Comparison Quote? Upload a copy of your current policy Upload or drag files here Required Period of Cover Start Date End Date Previous Next Select the type of cover you would like for your business Public Liability / General Business LiabilityTools and Portable EquipmentPersonal Accident & Sickness InsuranceWorkers Compensation InsuranceMobile Plant and MachineryBusiness use Motor Vehicle InsuranceCyber Risk InsuranceManagement Liability InsuranceCover for a workshop, office, or business premiseHome insurance for a Home based businessOther (please specify below) Based on your selection, we might need more information from you. Please continue and complete the form below though one of our brokers will call you to discuss what type of cover is appropriate for your business based on your selection. General Business Liability Do you or any of your employees, contractors, or subcontractors perform any work in connection with any of the following? Digging or Working at depths of more than 2mWorking at heights above 10mWorking on buildings more than 3 storeys highAirside at Airports / Aircraft / AviationAsbestosCladding / Aluminium Composite Panels / Foam PanelsCivil Works (Roads, Highways, Bridges, Tunnels, Dams, Sewer, Water Supply)Hazardous Goods Storage or Waste managementDemolitionMining or Mine SitesOffshore PlatformsPool Construction or MaintenancePublic Utilities, gas production, petrochemical plants or power stationsRail (Traditional or Light)ExplosivesWaterproofing What type of projects or worksites do you work on? ResidentialCommercialIndustrialGovernmentRural / FarmingOther Do you engage subcontractors? NoYes Do they hold their own Liability and Workers Comp? NoYes Estimated payments to subcontractors next 12 months Do you engage labour hire or hired-in labour? NoYes Estimated labour hire spend next 12 months Do you import any goods? NoYes Does the business import any of the following: Medical/pharma/veterinary products (incl. medicines, instruments/equipment)Gases or air under pressureAircraft and/or aircraft componentsFirearms, fireworks, ammunition, explosives and/or their component partsSelf-propelled vehicles/rolling stock and/or critical components (frame, brakes, tyres etc.)Tobacco and/or vaping productsBlood and/or blood productsChemicals (cosmetics, pesticides, insecticides, industrial chemicals)StockfeedCured and/or fermented meatProducts for children up to 4 years of ageToys, bicycles, playground equipment (all ages)Mechanised sporting/gym equipmentHydraulic lifting equipmentFood products from China/Hong Kong/Taiwan/IndiaVitamins/supplementsSafety/personal protective equipmentProducts subject to mandatory Australian safety standards / not compliant Details of products / countries / turnover Do you intend to use, store, or handle hazardous substances (incl. asbestos)? NoYes Discharge hazardous waste into atmosphere, sewer, or elsewhere? NoYes Do you hire out equipment or staff? NoYes Is there a Hire Agreement with a disclaimer or legal waiver in place that the hirer signs before hiring? NoYes Is all equipment checked and maintained after each hire? NoYes Please confirm each type of equipment you hire out, and the approx turnover ($) received for hiring out each type of item Does the business hire out any of the following: Elevated work platforms/scaffoldingMini excavators or skid steersSelf-propelled vehicles/plant without an operatorMotorised cutting/sawing equipmentOther general tools or machinery hireTrucks or motor vehicles without an operatorWatercraftJumping castlesMedical or surgical equipmentOther Annual payments you receive from hiring out your staff to others Do you export goods? NoYes Export to USA/Canada? NoYes Details (products, destinations, turnover) Any Hold Harmless agreements? NoYes In which state(s) does the business generate turnover/income? ACTNSWVICQLDSAWATASNTInternational Limits of Liability and Excess/Deductible Public Liability / Products Liability (any one claim and aggregate) —Please choose an option—$5,000,000$10,000,000$20,000,000Other Limit of cover for Property of others in your Care, Custody or Control —Please choose an option—$50,000$100,000$200,000$500,000Other Preferred excess/deductible for Personal Injury Claims Preferred excess/deductible for Property Damage Claims Do you require any additional extensions of cover? Victorian Plumbers – Consumer Protection LiabilityQueensland Electricians – Consumer Protection LiabilityErrors and Omissions CoverStatutory Liability CoverContractual Liability and Legal Expenses CoverOther Portable Equipment and General Property This section is for portable general property (tools, business equipment or stock) while away from the listed premise. Is General Property Cover required for equipment or stock away from the premise? NoYes Unspecified Business Items Description Unspecified Business Items Sum Insured (AUD) Do any Business Items need to be specified? NoYes Specified Business Items Description – Item 1 Sum Insured – Item 1 (AUD) Description – Item 2 Sum Insured – Item 2 (AUD) Description – Item 3 Sum Insured – Item 3 (AUD) Description – Item 4 Sum Insured – Item 4 (AUD) Description – Item 5 Sum Insured – Item 5 (AUD) Tip: For specified items, include make/model/serial and replacement value (incl. GST). General Property Excess (AUD) Personal Accident & Sickness Insurance This cover is for named individuals who are Sole Traders or part of a Partnership who are unable to arrange Workers Compensation insurance, or for employees of companies that have workers compensation but would like additional insurance for outside working hours. Named Insured Person 1 First Name Last Name Date of Birth State—Please choose an option—ACTNSWNTQLDSATASVICWA Scope of Cover—Please choose an option—Outside working hoursWorking hours only24/7 (anytime) Cover Type—Please choose an option—Injury onlyInjury & Sickness Current weekly income before tax (AUD) Capital Benefits – Sum Insured (AUD) Weekly Disablement Benefit – Sum Insured (AUD) Waiting Period (days) Number of Weeks Cover for Weekly Benefits Would you like an Agreed Value weekly benefit limit? NoYes Agreed Value Weekly Disablement Benefit – Sum Insured (AUD) Do you want to include optional Business Expenses Cover? NoYes Business Expenses weekly benefit – Sum Insured (AUD) Named Insured Person 2 First Name Last Name Date of Birth State—Please choose an option—ACTNSWNTQLDSATASVICWA Scope of Cover—Please choose an option—Outside working hoursWorking hours only24/7 (anytime) Cover Type—Please choose an option—Injury onlyInjury & Sickness Current weekly income before tax (AUD) Capital Benefits – Sum Insured (AUD) Weekly Disablement Benefit – Sum Insured (AUD) Waiting Period (days) Number of Weeks Cover for Weekly Benefits Would you like an Agreed Value weekly benefit limit? NoYes Agreed Value Weekly Disablement Benefit – Sum Insured (AUD) Do you want to include optional Business Expenses Cover? NoYes Business Expenses weekly benefit – Sum Insured (AUD) Previous Next Insurance Claims History Have you had any claims during the past five (5) years, whether you were at fault or not, relating to the proposed insurance? NoYes Please provide details for each claim below or upload a Claims History document. Claim 1 Date of Claim Brief Description of Claim Insurer Amount of Claim What actions have you taken to prevent a similar issue from occurring again? Claim 2 Date of Claim Brief Description of Claim Insurer Amount of Claim What actions have you taken to prevent a similar issue from occurring again? Upload Claims History Document Upload Claims History Document (optional) Upload or drag files here Are you aware of any circumstances or incidents which may give rise to a claim? NoYes Please provide details Additional Information Additional Information Additional Information Attachments Upload or drag files here Important Information Cooling Off If you are not completely satisfied with your policy, you may cancel it by notifying us in writing within 30 days of cover having commenced. You will receive a refund of the amount you have paid unless something has occurred for which a claim may become payable under the policy. Confirming Transactions You may contact us, in writing (which is always required if you are advising cancellation) or by phone, to confirm any transaction under your policy. Any transaction will be documented by us as quickly as possible. Code of Practice A self-regulatory Code of Practice exists for the general insurance industry, designed to raise overall standards. We have adopted the Code, details of which can be obtained from your insurance broker or our office. Complaints If you do not agree with any decision we make in relation to your insurance, please write to us stating what you disagree with and why. We will then either resolve or attempt to resolve your complaint immediately or refer the matter to our Internal Dispute Resolution Committee (IDRC). If you are not satisfied with a claim decision by the IDRC, the matter may be referred to an independent alternative dispute resolution body, the Australian Financial Complaints Authority (AFCA) provided it falls within their jurisdiction. Privacy We respect your privacy and comply with the Privacy Act and the National Principles. A copy of our Privacy policy is available upon request or on our website. Duty of Disclosure Duty to not misrepresent Your duty when you apply for insurance Before you enter into an insurance contract, you have a duty to not misrepresent under the Insurance Contracts Act 1984. You must take reasonable care not to make a misrepresentation. This means giving us true, complete and accurate answers to our questions, including where you provide information on someone else’s behalf. We use your answers to decide whether to insure you and on what terms. If you do not tell us something If any of your answers are misleading, incomplete, inaccurate or fraudulent we may reduce or not pay a claim, cancel your policy, or treat it as if it never existed. Have you or any partner, principal, shareholder or director of the business ever been / had: Insurance declined, cancelled, renewal refused or special conditions imposed by an insurer? NoYes Please provide details Declared bankrupt? NoYes Please provide details Involved in a company or business which became insolvent or subject to any form of insolvency or voluntary administration (e.g., liquidation or receivership)? NoYes Please provide details Convicted of any criminal offence within the past 5 years (other than minor traffic convictions)? NoYes Please provide details Liable for any civil offence or pecuniary penalty exceeding $5,000? NoYes Please provide details Are there any other matters that you should or would like to disclose? NoYes Please provide details Declaration I hereby declare that: My attention has been drawn to the important notices accompanying this Application form and further I have read these notices carefully and acknowledge my understanding of their content by my signature below. The above statements are true, and I have not suppressed or mis-stated any facts and should any information given by me alter between the date of this Application form and the inception date of the insurance to which this Application relates I shall give immediate notice thereof. I authorise you to collect or disclose any personal information relating to this insurance to/from any other insurers or insurance reference service. Where I have provided information about another individual (for example, an employee, or client), I declare that the individual has been or will be made aware of that fact and the section in the Policy on “The way we handle your personal information”. I also confirm that the undersigned is authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this Application form and I complete this Application form on their behalf. Details of Person Completing This Proposal First Name Last Name Job Title / Company Position Signature Date Previous Next
