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)?

Project Description

Please give a full description of the project work you will be undertaking.
By giving a full description the insurer gets an understanding of what you do and can then favourably rate your premium.

Total Value of Project:$

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 full time employees (include principals)

Number of part time employees

Estimated turnover of the business per year $

Do you import or export goods/products?
Yes    No

Will you be:
- Performing work at mine sites, either above or below ground?
- Providing products or services intended for use in the mining industry? Yes    No

Will any of your projects be involved in the following areas?

• Aircraft / Airports / Airlines Radar installations
• Chemical &/or pharmaceutical Manufacturing
• Dams
• Defence Installations
• Oil and/or Gas Production or Pipelines
• Public Utilities (ie Power Plants, Water, Communication)
• Railways
• Shipping / Port Authorities
• Watercraft or Marine Vessels

Contractors

Are you responsible for the hiring or selection of contractors?
Yes    No

Do you instruct contractors on how to perform their works / contracts?
Yes    No

Insured's History

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 any special conditions imposed?
• Suffered a loss whether insured or not (last 5 years only)?
• Been involved in a company that has declared bankruptcy or insolvency?
• Been charged or convicted for any criminal offence?

WARNING: Signing of Contracts:

There are potential insurance ramifications of signing contracts without appropriate legal advice. Many contracts have hold harmless clauses included in them and put the insured in a situation where they may not be covered under their liability policies. This policy has an exclusion relating to Contractual Liability. Basically, the exclusion states that the Insurer will only provide indemnity for any contractual liability where the signing of the contract does not increase the insured's liability beyond what would have applied had the contract not been signed.

Declaration

By submitting this Declaration, the Applicant declares that:

• 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;

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.