General And Products Liability Insurance 1 Details of Applicant 2 General Liability Questions 3 Declaration Section 1 - Details of Applicant 1. Insured Entity Type (please select): Sole TraderPartnershipPrivate Company (Pty Ltd)Unlisted Limited CompanyPublic Listed CompanyTrustNot for profit / Association 2. Insured Name: 3. Trading Name (if applicable): 4. ABN/ACN: 5. Insured's Registered Address: Place where business is registered/place of incorporation. 6. Insured's Website Address: Insured does not have a website 7. Occupation / Business Description: Please provide a detailed description of all business activities including the activities of any related entities. 8. Period of Insurance: From: 4pm local standard time To: 4pm local standard time 9. Limit of Indemnity: $ 10. Annual Revenue / Turnover a. Last 12 months (AUD): If new or trading less than 12 months, estimate for 12 months. b. Estimated next 12 months (AUD): 11. Staff Size: Stamp Duty and GST 12. Is the Insured domiciled in Australia with no subsidiaries outside Australia or New Zealand? YesNo a. If NO, is the Insured domiciled in Australia? YesNo b. If NO, where are the Insured's overseas subsidiaries? Please list countries and indicate percentage of total revenue. 13. In respect of gross fees/income for the last financial year, provide a breakdown by State: If the Insured has declared Overseas Turnover, complete the table below. 14. Is the Insured exempt from GST? YesNo 15. Is the Insured exempt from Stamp Duty? YesNo a. NSW Small Business Exemption I declare that the insured is a small business and qualifies for the NSW small business stamp duty exemption. I have obtained a signed declaration from the insured and will provide a copy on request. YesNo b. Other Exemption I declare that the insured is relying on a stamp duty exemption. I have a copy of the exemption certificate or declaration and will provide on request. YesNo Previous Next Section 2 - General Liability Questions Property in Care, Custody or Control 1. Do you require cover for property damage in your care, custody or control? YesNo Cover is limited to the standard 250,000 AUD sub limit unless agreed in writing. If YES, provide details of the property and total value: Details of Premises 2. Premises occupied for conducting the business (include overseas locations). Estimated Payroll 3. Estimated annual payroll including earnings of principals, directors and partners. Management, clerical and sales Manufacturing Work away from premises Total Contractor, Subcontractor and Labour Hire 4. Describe the nature of work performed and confirm volumes. Contractors Subcontractors Labour hire 5. Do you require all contractors or subcontractors to provide evidence of Public Liability, Products Liability and Workers Compensation before starting work? If YES, confirm the limit and any special requirements. 6. Do you on hire labour internally? YesNo If YES, give full details including entities, work and estimated annual wages. Estimated Turnover 7. Turnover split by major business activity or product. 8. Location split of next year estimated turnover: 9. Location split of current year actual turnover: 10. If you import any products into Australia, provide details. 11. If you export products from Australia, provide details. 12. Do you have formalised quality control processes? YesNo If YES, provide details: 13. Do you have any AS or ISO certifications? YesNo If YES, provide details: 14. Do you perform independent testing on all imported products? YesNo 15. Do you undertake or do others undertake on your behalf any welding or other hotworks? YesNo If YES, detail type of work: If YES, do you ensure all work is in full compliance with AS1674? YesNo 16. If involved in food production, preparation, packaging or handling, do you have HACCP certification? N/AYesNo 17. Do you have any involvement with dangerous goods or hazardous materials? YesNo If YES, provide details: 18. Give details if you or contractors work on or around watercraft, aircraft, airports, rail, oil and gas, mines, power or other high hazard locations. Professional Corporate Information and Design 19. What advice, design or specification do you provide to other parties? 20. Is the advice, design or specification charged for a separate fee? YesNo If YES, give precise details: 21. Do you manufacture any products to the design or specification of others? YesNo If YES, provide details: 22. Do you provide written reports to clients? YesNo 23. If YES, describe the nature of reports and include any disclaimers or warranties: Accreditation and Risk Management 24. Do you have a formal Quality Assurance Plan or Program in place? YesNo 25. Do you carry any Quality Assurance or Control accreditation or certification? YesNo If YES, provide details: Liability Assumed under Contract 26. Do you assume liability under contract or hold others harmless or agree to waivers (other than lease liability)? YesNo Provide full details of contracts and scope of works for review. Insurance History 27. Are you currently insured for Public and Products Liability, Professional Indemnity or Workers Compensation? YesNo If YES, complete the table. Policy Expiry Limit ($) Excess ($) Insurer Public and Products Liability Professional Indemnity Workers Compensation 28. Has the proposed insured or any subsidiary ever had a policy declined, refused or cancelled? YesNo If YES, provide full details or attach addendum: 29. Has the proposed insured or any subsidiary ever had a policy voided or rescinded? YesNo If YES, provide full details or attach addendum: Prior Knowledge and Claims Experience 30. Has the proposed insured been subject to a claim over the past 5 years? YesNo If YES, give date, description and amount paid or settlement: 31a. Have there been any claims made against the insured or any loss or expense incurred which may fall under this insurance? YesNo 31b. Have any circumstances occurred which may give rise to such a claim or loss? YesNo If YES to either, provide details: Incurred means settlement made, legal fees, defence costs or reserved amounts. 32. Have you or any person or party comprising the insured ever been convicted of a criminal offence, liable for civil penalties, or been bankrupt or insolvent? YesNo If YES, give full details including dates and circumstances: Previous Next Declaration This section is compulsory. The undersigned declares that the statements and particulars in this proposal form are true and that no material facts have been misstated or suppressed after enquiry. We agree that should any of the information given by us alter between the date of this proposal and the inception date of the insurance to which this proposal relates, we will give immediate notice thereof. We agree that the insurers may use and disclose our personal information in accordance with the “Privacy Statement” at the beginning of this Proposal. The undersigned acknowledges that they have read this Proposal Form, including all Important Notices, as well as the policy wording and associated endorsements, and are satisfied with the coverage provided, including the limitations and restrictions on coverage. We agree that this proposal, together with any other information supplied by us, shall form the basis of any contract of insurance effected thereon. To be signed by the insured for whom this insurance is intended for Full Name: Position: Signature: Date: Important: The undersigned of the declaration above is fully aware of the scope of this insurance so that these questions can be answered correctly. In doubt, please speak with your insurance broker, agent or advisor, as non-disclosure or misrepresentation in this proposal may affect an insured’s right of recovery under the policy. We recommend that you keep a record of all information supplied for the purpose of entering into an insurance contract (including copies of this proposal form and correspondence). Important Notices Notification of Occurrences or Events which may give rise to a Claim If during the period of this Policy you become aware of any occurrence which may give rise to a Claim under the Policy and during the period of insurance give written notice to the Insurer of such occurrence, any Claim which may be subsequently made arising out of that occurrence shall be deemed to be a Claim made during the period of this Policy whenever such Claim may actually be made. Previous Next
