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

Phone No. *

Occupation: Plumber

When did the business start (year)?

Please supply a split of your work activities as a %e:

 %   Residential dwellings

 %   Small Commercial

 %   Large Commercial

 %   Other

If you have placed a percentage amount in "Other" above, please give full details:

Cover Required

Please nominate the amount of cover you require:

$5,000,000

$10,000,000

$20,000,000

Underwriting Questions

No. of full time employees:

No. of part time employees:

What is your annual business turnover?

Do you, or do you intend to use, store or handle hazardous substances?
Yes    No

Do you discharge waste or hazardous material into the atmosphere, sewer or elsewhere?
Yes    No

Do you carry out any of the following: Use of explosives, bridge construction/maintenance, demolition activities, construction or maintenance work involving chemical works, defence, mines, offshore platforms, aircraft or aviation risks, utilities, gas production, petrochemical plants, power stations, rail, ships or marine risks?
Yes    No

Is any work performed by or on behalf of the insured at or on any of the following:-

• the part of an airport used by aircraft for loading and unloading and takeoffs and landings
• offshore platforms and rigs,
• watercraft exceeding 20 metres in length,
• underground mine shafts or tunnels
• demolition of buildings or other structures exceeding 5 metres in height
• subaqueous / underwater work
• railway signalling or working within the rail corridor
• construction and/or structural maintenance of dams/reservoirs or weirs
• petrochemical plants or refineries
• power stations

Do you, or do you intend to carry out underground/excavation work exceeding 3 metres in depth?
Yes    No

Is work carried out limited to domestic and light commercial only?
Yes    No

Does the business take on individual contracts that exceed $100,000?
Yes    No

Does any of your work involve fire sprinkler systems?
Yes    No

Do you perform "hot work" away from own premises that involves the use of cutting, welding, grinding or soldering equipment?
Yes    No

Do you import or export goods/products?
Yes    No

Do you hire out equipment and/or staff?
Yes    No

Contractors

Do you employ contractors or sub-contractors?
Yes    No

If you answered YES
Estimated annual payments to these contractors?

Do they have their own Public Liability cover?
Yes   No

Labour Hire

Do you use labour from labour hire companies?
Yes    No

Your History

Have you or anyone to be insured under this policy:

• 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 declared bankrupt or become insolvent?
• Been charged or convicted for any criminal offence?

Declaration

By submitting this Declaration, the Applicant acknowledges:

• they are authorised by each of the other Applicants to make this Declaration,
• the contents of the Declaration are true and complete,
• they are under a continuing obligation to immediately inform the insurer of any change in the particulars or statements contained in this Declaration or in the accompanying documents up until the contract is entered into,
• 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: