Single Project / Annual Projects Contract Works Application Form. Proposer's Details. Name of Insured. Broker Address* ABN (if applicable)

Transcription

1 Single Project / Annual Projects Contract Works Application Form Proposer's Details Name of Insured Broker Address* ABN (if applicable) Client Address Clients Suburb State Client Postcode* Financial Interested Party Have You (the insured) or any of Your Directors ever had any insurance declined or cancelled by an insurer or had any special conditions imposed or suffered a loss where the cause relates to arson or fraud in the last five years? Please provide details Have You (the insured) or any of Your Directors, Officers or Senior Staff of the Insured ever been Bankrupt or been a Director of an organisation that was placed in Receivership, liquidation or provisional liquidation? Please provide details Have You (the insured) or any of Your Directors had any incidents, prosecutions (or attempted) prosecutions, fine or penalty under any Government legislation or from any Authority in regards Your business, or any Penalty adjustments from including under OH & S, Environmental, Fatigue or the like? Please provide details

2 Proposer's Details (cont.) Have You (the insured) or any of Your Directors suffered any loss the subject of which You are submitting to be insured, or made any claims on any construction policies, or construction related policies in the past five years? Number of claims Total Cost of all claims last 5 years $ Please provide full details

3 Basis of Insurance Projects Policy Inception Date te: This is a 12 month policy period that will commence at 4.00 p.m. on the selected date. Type of Policy: One Off Single Project (Excluding Residential Owner Builder) Annual Projects Residential Owner Builder Annual - Pay As You Go Low Cost Deposit Annual Policy Option* Policy Inception Date: Policy Expiry Date: Maximum Project Duration: Maximum Defects Liability Period: Months Months *Annual Pay As You Go (Low Cost 20% Deposit Basis Annual Policy for Turnovers up to $2 Million) - (Annual PAYG policy provides a Material Damage Automatic Limit of $100,000 Ability to Add & Pay for New Specified Projects Online During Policy Period) Cover Options: Contract works Material Damage Only Contract works Material Damage Public/Product Liability Existing Structure (domesbuildin Total replacement value of existing structure* $ te: cover provided for contents Plant and Equipment (te: t available for Residential Owner Builders) Plant and Equipment Formworks, Hoardings, Temporary Buildings, Scaffolding, Major Plant Value* $ Details of Items* Construction Tools, Minor Plant (Individual Item Limit $5,000) Value* $ Details of Items*

4 Scope of Works / Project Particulars Project Description(te: Only complete for Single Project and Residential Owner Builder Policies.) Single dwellings (new) Other residential Alteration and Additions n residential - retail / commerical n residential Other Detailed Scope of Works Business Activities(te: Only complete for Annual Policies.) Single Dwellings(new) Other Residential n Residential Retail/Commercial n Residential Other Other % % % % % Total (Must add up to 100%) *If other, please provide details: Single Project / Residential Owner Builder Specified Project Location (te: Only complete for Single Project and Residential Owner Builder Policies.) Site Address of works Site Suburb of works Site state of works Site postcode of works* Is the surrounding property less than 900 millimetres from boundary Please describe the property bordering the Project Site and it's proximity to the work being undertaken?

5 Project Particulars (cont.) Annual Policy Geographic Scope of Works (te: Only complete for Annual Policies.) Territorial Limits: Cover Provided anywhere in Australia South of 25th Parallel. Please advise percentage of work in each state: NSW-M VIC-M QLD-M SA NSW-C VIC-C QLD-C ACT WA NT TAS Above 25th-Parrallel Total ( Must add up to 100%) C = Country, M = Metro Annual Policy - Basis of Insurance Projects (te: Single Project and Residential Owner Builder Policies issued on Project Run-Off Basis Only.) A) Annual Turnover Basis* (*estimate the value of all the actual work that You will do in the Period of Insurance.) Do you require insurance for all Projects on-hand at the commencement of, and Projects commenced during, the Period of Insurance (plus Defects Liability Period)? OR B) Project Run-Off Basis* (*estimate the value of all Contracts to be commenced during the Period of Insurance.) Do you require insurance for all Projects as each commences during the Period of Insurance and until they are completed, within the Maximum Project Duration envisaged (plus Defects Liability Period)? Has any project already commenced? Building or Industry Experience: Less than 3 years More than 3 Years If or Less than 3 years building experience then provide details (if any projects already commenced provide us with details, works completed description, completed value, date project started, reason for request, confirmation that previous insurer unable to runoff under previous policy, whether previous builder went into administration)

6 Project Activities Does the Project involve any of the following? (if you are unsure then select yes and provide details at the end of this application) (a) Excavation deeper than 3.5 metres (b) Demolition Projects and or any Blasting Contracts or operations - or Liability from any unlicensed operators/operations. (Unless forming part of the residential or commercial construction project deemed as Ancillary Demolition no greater than 2 storeys) (c) Buildings or structures of historical significance which are heritage listed or National Trust Properties (d) Any Projects involving work airside or around aircraft or watercraft and plant attached or any work being carried out from aircraft or watercraft (e) Any Civil Contracts for example: - Roadworks, Railways, Runways, Dams, Tunnels, Bridges, Irrigation systems, Subdivision establishment, Reservoir, Siphon works, Pipelines, Canals, Underground works, Shafts or galleries- (Unless forming part of the residential or commercial construction project limited to excavation for buildings, foundations and ancillary civils or drive-way entrance work limited to 25% of total project contract cost and excavation limited to 3.5 metres) (f) Will any project be located rth of the 25th Parallel (g) Erection of scaffolding unless part of a construction project and in excess of 3 storey's (h) Projects exceeding 6 storey's in height (i) Jetties, piers, wharves, marina, breakwaters or any work in, on or over the sea or a lake (j) Manufacturing Risks (k) Projects on off shore Islands (l) Swimming pool building only(unless forming part of the residential or commercial construction project) (m) Pure landscaping contractors, Boilermakers, Scaffolding projects or Waterproofing only contracts, Maintenance only Contracts - (Maintenance ancillary/associated are permitted) (n) Labour Hire (as agency) (o) Refurbishment or construction of schools, hospitals, universities, shopping centres, hotels or railway stations (p) Any Unusual, Unproven, Experimental or Prototypical Projects (q) Erection of machinery or plant (EAR Policies)(unless the component is part of our insured residential/commercial project and less than 25% of total contract cost) (r) Projects involving Underpinning, or any Weakening or Removal of Supports (s) Storage (other than of construction materials) (t) Installation of above ground steel tanks (other than residential) (u) Any project involving Asbestos (v) Has the proposed project location been susceptible to flooding?

7 Contract Works Section One - Material Damage Estimate the value of all the actual work that You will do in the Period of Insurance in the next 12 months (Include Principal Supplied Items Value which must be full replacement value) (Policy Maximum Limit for Principal Supplied Items is $1,000,000)* or Estimated value of contracts to be commenced in the next 12 months (Include Principal Supplied Items Value which must be full replacement value) (Policy Maximum Limit for Principal Supplied Items is $1,000,000)* Maximum Value of any Contract*: $ $ te Sub Limit as follows: Escalation of Contract Value Expediting Expenses Mitigation Costs 15% 5% 5% Removal of Debris 10% Professional Fees 10% Transit Off Site Storage Are these sub limits acceptable $100,000 $100,000 Section Two - Public Liability Limit of Liability Required $5,000,000 $10,000,000 $20,000,000 DEPOSIT PREMIUM (te: It is a condition of the policy that the named insured complete a declaration at the policy expiry) Please select the required Deposit Premium to apply to your quotation (te: Annual Policies default deposit premium is 100%) 20% Pay As You Go Annual (Only Applicable for Clients with Annual Turnovers up to $2,000,000) 75% 100%(te: All Single Project / Residential Owner Builder Policies are 100% Deposit Basis) EXCESS OPTIONS Please choose the level of Material Damage excess to apply to the policy (te: Standard is $1,000) $1,000 $2,500 $5,000 $10,000 Other $

8 Terms and Conditions & Policy Declaration (cont.) Insurer tices Pursuant to the Insurance Contracts Act your duty to disclose all relevant information is set out below. NON-DISCLOSURE If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the policy in respect of a claim or may cancel the policy. If your non-disclosure is fraudulent, the insurer may also have the option of voiding the contract from its beginning. It is therefore vital that you enquire of all entities comprising the insured, including senior staff, before completing the proposal form and before you sign any declaration confirming no change in the information disclosed. PRIVACY POLICY esentry Underwriting respects your privacy and complies with the Privacy Act and the National Privacy Principles. A copy of esentry Underwriting's privacy information is available from our website at AVERAGE POLICY CONDITION "Average" applies to some sums insured in the Policy. This means that in circumstances where you are required to specify a particular value (e.g. market value or replacement value) and the amount you specify is inadequate, any claim on an aspect of the Policy subject to "Average" will be paid in the same proportion as the amount you specified bears to 90% of the value which was required to be specified Surrender of Waiver of any Right of Contribution or Indemnity If another person or company is liable to compensate you or hold you harmless for part or all of any loss or damage otherwise covered by your policy, but you agree with that person or company (either before or after the inception of your policy) that you would not seek to recover any loss or damage from them, the policy will not cover you for this loss or damage. POLICY In order to understand the insurance you are proposing, you must read the Policy. Anything you state in this proposal form may be included in the Policy. If you propose something which esentry Underwriting do not want to insure, or more information is required, esentry Underwriting will contact you. Important tices This statement tells you how we collect, use and disclose personal information "Personal Information" is information about and which identifies individuals, including, for example, an individual who is an insured and an individual who may simply be referred to in the application for cover or claim form (such as a director, claimant, witness etc). It is important you read, understand and agree to the following, which applies from 21 December 2001

9 Terms and Conditions & Policy Declaration (cont.) What We Do We collect personal information from you to be able to provide you with our various services. These may include, insurance broking, claims management, and other forms of insurance services that may include, employee benefits, superannuation and investment advisory services. Other purposes include helping to develop and identify products and services that may interest clients, developing, establishing and administering alliances and other arrangements with other organisations in relation to the promotion, administration and use of our products and services. For more information on our services please contact us. We disclose personal information to third parties who we believe are necessary to assist us in providing our services. For example, in arranging and managing your insurance needs we will usually provide information to insurers, other insurance intermediaries, our advisers such as loss adjusters, lawyers and accountants, and others involved in the claims handling process. We also provide it to purchasers of our business and related companies. We limit the use and disclosure of any personal information provided by us to third parties for the specific purpose for which we supplied it (except with the individual's consent). We take reasonable steps to ensure that whenever we collect, use or disclose personal information, it is accurate, complete, and up-to-date. What We Expect of You When you provide us with personal information about other individuals, we rely on you to have made them aware that you will or may provide their information to us, the purposes we use it for, the types of third parties we disclose it to and how they can access it (as described in this document). If it is sensitive information we rely on you to have obtained their consent to the above. If you have not done either of these things, you must tell us before you provide the relevant information. If we give you personal information, you and your representatives must only use it for the purposes we agreed to. Dispute Resolution Clients who are not satisfied with our services may contact our Compliance Officer. esentry Underwriting subscribe to the Financial Ombudsman Service (FOS) Dispute Facility, a free consumer service. Further information is available from our office and website. If you are not satisfied with any of our services, please contact our office. YOUR DUTY OF DISCLOSURE Before entering into a contract of general insurance, you have a duty, under the Insurance Contracts Act, to disclose every matter that you are aware of, or could reasonably be expected to be aware of, that is relevant to the insurer's decision whether to insure you and if so, on what terms. You have the same duty to disclose these matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance.

10 Terms and Conditions & Policy Declaration (cont.) Your duty however does not require disclosure of matters - that diminishes the risk to be undertaken by the insurer; that is of common knowledge; that the insurer knows of, in the ordinary course of our business, ought to know; as to which compliance with your duty is waived by the insurer. You should note that your duty continues after the proposal form has been completed until the policy is entered into, i.e. until the date we receive instructions to bind cover. APPLICATION DECLARATION Please sign below to acknowledge and accept this Declaration I, the undersigned, after enquiry, declare and confirm as follows: A. I am authorised by each of the persons or entities included in this insurance application (including all partners/principals/directors, if applicable) to: a. make this application; b. make these declarations; and c. accept the terms for this contract of insurance; on their behalf B. I have made all necessary enquiries into the accuracy of the responses given in this insurance application and confirm that the statements and particulars given are true and complete and that no material facts have been omitted, misstated or suppressed. C. I understand that I have a continuing obligation to immediately advise of any material changes to the particulars or statements contained in this insurance application. D. I acknowledge that the particulars and statements contained in this insurance application shall be the basis of, and will be incorporated into, the contract of insurance. E. I confirm that I have read and understood the content of the following: a. Terms and Conditions (including your Duty of Disclosure); b. Policy Wording and any applicable Endorsement Wordings. F. We authorise esentry Underwriting P/L to give to and obtain from any insurers or previous brokers any information relating to our insurance history as well as insurance claims information obtained during the course of this contract. If you do not agree to the above, please contact esentry Underwriting on Application Date: Application Signature: