Public and Products Liability Proposal Form

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1 Public and Products Liability Proposal Form Solution Underwriting Agency Pty Ltd Level 5, 289 Flinders Lane Melbourne, Victoria. Australia 3000 T F / 1

2 Important Facts Your duty of disclosure This policy is subject to the Insurance Contracts Act 1984 (Act). Under that Act you have a Duty of Disclosure. Before you take out insurance with us, you have a duty to tell us of everything that you know, or could reasonably be expected to know, may affect our decision to insure you and on what terms. If you are not sure whether something is relevant you should inform us anyway. You have the same duty to inform us of those matters before you renew, extend, vary, or reinstate your contract of insurance. The duty applies until the policy is entered into, or where relevant, renewed, extended, varied or reinstated (Relevant Time). If anything changes between the time the answers are provided to us or disclosures are made and the Relevant Time, you need to tell us. Your duty however does not require disclosure of matters that: reduce the risk; are common knowledge; we know or, in the ordinary course of our business, ought to know, or we have indicated we do not want to know. If you do not comply with your duty of disclosure, we may be entitled to: reduce our liability for any Claim; cancel the contract; refuse to pay the Claim, or avoid the contract from its beginning, if your nondisclosure was fraudulent. Privacy In this Privacy section we, us or our means Great Lakes Australia and Solution, unless specified otherwise. We are committed to the safe and careful use of your personal information in the manner required by the Privacy Act 1988 (Cth) and the Australian Privacy Principles. We collect your personal information in order to assess your application for insurance and, if your application is accepted, to administer and manage your policy and respond to any Claim that you make. To do this, your personal information may need to be disclosed to reinsurers and service providers and related entities who carry out activities on our behalf, such as assessors and facilitators, some of whom may be located in overseas countries. Our contractual arrangements generally include an obligation for these reinsurers, service providers and related entities to comply with Australian privacy laws. By providing us with your personal information, you consent to the disclosure of your personal information to reinsurers, service providers and related entities in overseas countries to enable us to assess your application, to administer and manage your policy and to respond to any Claim that you make. If you consent to the disclosure of your personal information to overseas recipients, and the overseas recipient handles your personal information in a way other than in accordance with the Australian privacy laws, we may not be responsible for the handling of your personal information by the overseas recipient. If you choose not to provide your personal information and/or choose not to consent and/or withdraw your consent to the disclosure of your personal information at any stage, we may not be able to assess your application or administer and manage your insurance policy and respond to any Claim that you make. Our Privacy Policies contain information on how you may access personal information that each of us hold, or seek correction of your personal information and information on how to make a complaint about the handling of your personal information and how complaints are handled. If you require more information, you can access the Great Lakes Australia Privacy Policy and Privacy Statement at privacy_statement.aspx You can also download a copy of Solution s Privacy Policy by visiting au/uploads//downloads/privacy_policy_statement.pdf We are committed to protecting your privacy. We only use the personal information you provide to us to quote on and insure your risks. We only provide personal information to our Insurers and reinsurers (and their representatives) and those we appoint to assist us with Claims under your policy. We will not trade, rent or sell your information. If you don t provide us with complete information, we cannot properly quote for your clients insurance and we cannot insure them. You can check the personal information we hold about you and your clients at any time. General Insurance Code of Practice Great Lakes Australia is a signatory to the General Insurance Code of Practice. The Code aims to raise standards of service between insurers and their customers. For any information about the Code, including a copy of the Code, contact the Financial Ombudsman Service on or visit www. codeofpractice.com.au 1 / 9

3 About you Name in full of all entities to be insured including subsidiaries: Company Name(s): A.B.N: I.T.C%: Postal Address: Full description of your business: Number of years in continuous operation: Your website: Please provide details of all premises occupied for the purpose of conducting your business: Premises 1: Premises 2: Premises 3: Owned Leased Owned Leased Owned Leased 2 / 9

4 Period of Insurance From: To: at 4pm at 4pm Limit of Indemnity Public Liability: any one Occurrence Product Liability: annual aggregate Goods in your physical and legal control: annual aggregate Turnover Annual turnover past 12 months: Estimated turnover coming 12 months: NSW: VIC: QLD: SA: WA: TAS: NT: ACT: Other: 3 / 9

5 Payroll Managerial, clerical and sales: Payments: Staff Numbers: Manufacturing: Payments: Staff Numbers: Installation/work away from premises: Payments: Staff Numbers: Other: Payments: Staff Numbers: Contractors Do you use contractors and/or sub-contractors to perform work in you business? If yes, do they work under your direct supervision or control? What are the estimated annual payments?: What are the nature of work they carry out?: Are they required to carry their own insurance for; a) Public Liability Minimum Limit: b) Workers Compensation How is this checked?: 4 / 9

6 Labour Hire Do you use labour hire personnel supplied by labour hire companies in your business? If yes; Company: Type of Work: Annual Payments: Are you required to insure these personnel for Workers Compensation? Do you hire out your employees to third parties on a labour hire basis? If yes, what is the estimated annual turnover received?: What is the type of work they perform?: Please provide details of any of the following used in your business; Boiler/pressure vessels: Car parks: Unregistered vehicles (number and type): Lifting equipment (lifts, escalators, hoists, cranes etc): 5 / 9

7 Hazardous or dangerous substances stored at your premises; Substance: Quantity: Storage Method: Use of Substance: Products Please provide full details of all products for which insurance is required. (Please attach product brochures and any other appropriate documents). Description: Function: Manufactured (M) Imported (I) Distributed (D) Exported (E) Turnover: Origin / Destination: Do you modify, re-label or re-package any of the products you import, export or distribute? Are any of your products used in motor vehicles, aircraft, watercraft, hovercraft, rail equipment, power stations, chemical plants or mines? 6 / 9

8 Do you manufacture any petrochemicals, industrial chemicals, pesticides, fungicides, fertilizers or radioactive materials? Please provide details of the quality control procedures for all your products (including relevant industry codes or standards, testing details and frequency, recall procedures and record keeping): Have you ever recalled a product due to potential safety issues? Property of others in your physical and legal control In the course of your business, do you have in your possession the property of others in your physical and legal control? If yes, please give a description of the property: What is the value at all your locations at any one time: What is the maximum value of any one item: Is this property covered by any other policy? If yes, please give details including type of policy, policy number, insurer and policy period: 7 / 9

9 Contractual Do you assume the liability of others under contract or hold others harmless? If yes, please provide details and attach copies of agreements: Insurance and other history Has any insurer ever declined, refused to renew, cancelled or imposed special terms or conditions on any proposal, renewal or policy held by you? Have you ever had any criminal charges and/or convictions? Have you ever had financial trouble resulting in the appointment of an administrator and/or liquidator and or being declared bankrupt? Claims After investigation, have there in the past 7 years, been any Claims and/or uninsured losses and/or circumstances which could give rise to a Claim? If yes, please provide details (including the date of loss, a full description of the circumstances of the Claim, amount paid and the amount outstanding, amount of excess and whether or not the Claim has been finalized): 8 / 9

10 Declaration I/We declare that to the best of my/our knowledge and belief the answers given above, documents or papers submitted, represent the true position and that we have not withheld any information, material to this proposal. I/we acknowledge that no cover is provided unless and until; Solution Underwriting advise in writing of the cover and terms which they can provide, and this cover and terms is then accepted by me/us, and Solution Underwriting are advised by me/us of acceptance of their cover and terms offered, and Solution Underwriting acknowledges to me/us that cover is provided. Where answers in this proposal are not in my/our own handwriting, they have been checked by me/us and I/we agree that they are correct. I/we have read and understood the Important Facts at the beginning of this proposal. I/we authorize Solution Underwriting to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to or which may impact on this insurance cover, and any other insurances held by me/us and Claims under those insurances. I/we agree that this proposal and accompanying documents or papers shall form part of this proposal and are the basis of the insurance contract proposed. Signature(s) on behalf of the Proposers: Position: Date: 9 / 9

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