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.

NOTE: Extra questions may be asked (depending on your activities) once this form is received by our office.

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
$  

Business Activities

Offshore oil/gas facilities:
Yes    No

Onshore oil/gas facilities:
Yes    No

Mine Sites - Surface Operations:
Yes    No

Mine Sites - Underground:
Yes    No

Any other Site, away from the office:
Yes    No

Any Overseas, Offshore/Onshore facilities, Mine Sites or other Sites:
Yes    No

How much time would you spend at these facilities?
  (weeks per year)

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 or party comprising the Insured) ever made a claim or suffered a loss or had a claim declined including Worker to Worker and Subrogation claims or losses in the past 5 years?
Yes    No

Are you (or any person or party comprising the Insured) aware of any circumstances which may give rise to a claim?
Yes    No

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 a policy cancelled?
• Had a policy endorsed to include additional terms, premium loadings or deductibles imposed?
• Had any special conditions imposed?
• Suffered a loss whether insured or not (last 5 years only)?
• Been declared Bankrupt, Insolvent or had an Administrator/Liquidator appointed?
• Been charged or convicted for any 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

Claims Made Policy
The Professional Indemnity section of this Policy operates on a 'Claims made and notified' basis. This means that the Policy covers you for Claims made against you and notified to us during the Period of Insurance.
This Policy does not provide cover in relation to:

• acts, errors or omissions actually or allegedly committed prior to the retroactive date of the Policy (if a date is specified);
• claims made after the expiry of the period of insurance even though the event giving rise to the Claim may have occurred during the period of insurance;
• claims notified or arising out of facts or circumstances notified (or which ought reasonably to have been notified) under any previous Policy;
• claims made, threatened or intimated against you prior to the commencement of the period of insurance;
• facts or circumstances of which you first became aware prior to the period of insurance, and which you knew or ought reasonably to have known had the potential to give rise to a Claim under this Policy;
• Claims arising out of circumstances noted on the proposal form for the current period of insurance or on any previous proposal form.