Liability Renewal Declaration 1 Liability Renewal Declaration 2 People and Financials 3 Operations and Risk 4 Products Liability 5 Declaration and Submit Liability Renewal Declaration Policy Number Insured Name/s Website Address Please provide a description of your business activities and products, including any changes in the next 12 months Split of Activities Activity 1 % of turnover Activity 2 % of turnover Activity 3 % of turnover Ensure total equals 100 percent. Turnover Percent Split by State NSW VIC ACT QLD SA WA TAS NT Overseas Ensure total equals 100 percent. List of Locations business is conducted from Add one per line: Location and occupancy, Owned or Leased, Vacant or Occupied. Do any premises owned by you have exterior walls constructed with Aluminium Composite Panelling YesNo If yes, which premises and is the panelling compliant with building safety regulations Previous Next Headcount and Financials Number of full time equivalent employees - last 12 months Estimated number - next 12 months Annual gross wages - last 12 months Estimated annual gross wages - next 12 months Annual gross turnover - last 12 months Estimated annual gross turnover - next 12 months Contractors and Subcontractors Do you use contractors or subcontractors YesNo Are contractors or subcontractors required to hold their own Workers Compensation and General Liability policies prior to commencing work YesNo Do you obtain and store evidence of contractor insurance policies, including limits and expiry dates YesNo Services provided and estimated annual payments Labour Hire and Volunteers Do you use hired in labour or labour hire YesNo Is labour shared between entities under Insured that could be considered inter-company labour hire YesNo Services and estimated annual payments for labour hire Do you use volunteers YesNo If yes, please provide details of volunteer activities Please outline any health and safety training, inductions and equipment you provide for contractors, labour hire and volunteers Do you have documented incident reporting procedures in place YesNo Previous Next Contracts and Work Types Do you under any contract or agreement assume the liability of or hold harmless any other party other than lease liability YesNo If yes, please provide details Do you conduct any welding or hot work YesNo Do you perform any work away from premises YesNo If yes, please provide details Do you own or operate any unregistered vehicles or mobile plant and equipment YesNo If yes, please provide details Do you have any third party property in your care, custody or control YesNo If yes, please provide details Previous Next Products you manufacture, assemble, modify or repackage Add one per line: Product, intended use, estimated annual turnover. Products you import Add one per line: Product, country of origin, estimated annual turnover. Products you export Add one per line: Product, destination country, estimated annual turnover. Records, Standards and Recall Relevant records maintained for material supply, batch numbering and manufacturing processes, and minimum retention period Quality control or management standard certifications held Do you have a documented product recall procedure in place YesNo Previous Next Important Notices Please ensure to complete this declaration in full. If additional space is required for any response, provide details on a separate sheet. If any section does not apply, mark as N/A. Your duty of disclosure: before you enter into, renew, extend, vary or reinstate an insurance contract, you must tell us anything you know or could reasonably be expected to know that may affect our decision to insure you and on what terms. If you do not tell us something you are required to, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both. If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed. Privacy: any personal information collected will be handled in accordance with the insurer’s Privacy Statement. Declaration Name Position Date Signature I confirm I am authorised to complete this renewal declaration on behalf of the Insured and that the information is accurate and complete [acceptance* decl-consent] I agree Previous Next
