Contractors All Risks Proposal

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1 P F A.F.S Licence A.C.N Contractors All Risks Proposal IMPORTANT NOTICE This Proposal Form must be typed, or completed in ink and signed and dated by the Proposer: Please answer every question fully, and state NIL or NONE as applicable. Incomplete answers may not be accepted and can delay quotation. Should there be insufficient room in the Proposal Form for full details, please use the additional information section at the end of the Proposal. Please also attach any supporting information which you feel may assist us in understanding your professional business practice It is the duty of the Proposer to disclose all material facts to Underwriters. Where this is omitted, the Underwriters may avoid their obligation under the Policy. For the purpose of the Proposal and for all purposes relating to any policy issued pursuant to this Proposal, a material fact shall be deemed to be one that would be likely to influence an Underwriter s judgment and acceptance of your proposal. Upon acceptance of the Underwriters terms and conditions and payment of the premium, all information provided by the Proposer together with the guidance notes will be deemed to be incorporated in the contract between Underwriters and the Insured. Your Insurance includes a provision that has the affect of excluding or limiting OUR liability under the Insurance in respect of a loss by reason that you are, or have been, a party to an agreement that excludes or limits YOUR rights to recover damages from a party in respect of the loss. Copies of the Proposal Forms should be retained for your records. High Street Underwriting Agency - Contractors All Risk Proposal HSUA

2 YOUR DETAILS 1. Name Insured (Full names of all entities requiring cover including trading names): Commencement date of business: 2. Contact Details Business Address: Suburb: State: Postcode: Phone: Fax: Mobile: Website: PERIOD AND LIMITS OF INSURANCE 1. Period of Insurance 1) Insurance cover is needed from: to: BUSINESS PARTICULARS 1. Business Description Full description of your Business: 2. Experience 1) Experience of the Principal: years months 2) If you have been in business for less than 3 years, please give details of previous experience: 3. Principals/Directors Information 1) None of the principals or Directors of the Business have ever been: a. refused insurance or had any special terms or conditions imposed by an insurer. b. convicted of or have any prosecution pending for any offence involving dishonesty of any kind (e.g. fire, fraud, theft or handling stolen goods). High Street Underwriting Agency - Contractors All Risk Proposal HSUA

3 3. Principals/Directors Information Cont. c. declared bankrupt, the subject of bankruptcy charge proceedings or any voluntary or mandatory insolvency or winding up procedure. d. prosecuted or received notice of intended prosecution under any Health and safety at Work or Consumer Protection Act. If you answered '' for questions a to d, please give further details below: 4. Other Business Particulars 1) The Business has been insured in respect of Contractors All Risks claim free for the past 3 years. 2) Contracts are undertaken only within Australia. 3) Contracts are not undertaken in hazardous conditions including demolition, mining, dynamiting, underground, on or near water, on bridges etc. 4) Contracts are not taken in areas that are subject to cyclones, floods, earthquakes or natural catastrophe. If you answered '' for questions 1 to 4, please give further details below: 5. Business Contacts/Value Please confirm the following: The total estimated annual contracting turnover of The Business 1) (including the total estimated annual value of any free issue materials) 2) The maximum estimated value in respect of any one contract 3) The average estimated value in respect of any one contract 4) The maximum estimated contract period in respect of any one contract 5) The average estimated contract period in respect of any one contract 6) The total value of all employees tools to be insured $ $ $ months months $ 7) Details of the typical types of contract undertaken High Street Underwriting Agency - Contractors All Risk Proposal HSUA

4 6. Claims / Insurance History (a) Do you currently have insurance? Yes No - If 'Yes', please advise the name of the holding Underwriter: (b) During the past five years, have you ever had a claim made against you, or are you aware of any incident, accident or prosecution which could lead to a claim being made against you (whether insured or not)? Yes No - If 'Yes', please provide further details below: Date Particulars Cost Name of Insurer (if any) (c) Has any insurer ever declined indemnity for any claim made by you? Yes No - If 'Yes', please provide further details below: (d) Has any insurer declined, refused to renew, cancelled or imposed special conditions to any policy of insurance held by you? Yes No - If 'Yes', please provide further details below: High Street Underwriting Agency - Contractors All Risk Proposal HSUA

5 DECLARATION I/We declare and warrant that after enquiry all statements and particulars contained in this proposal and addenda are true and that no information whatever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this proposal and should the above particulars alter in any way I/We will advise the Underwriters as soon as practicable. I/We understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of the proposal may result in the Underwriters refusing to provide indemnity or voiding the policy in every respect. I/We hereby agree and accept that this Declaration shall be the basis of the contract between both parties if entered into. For and on behalf of (Name of Company): Signature : Dated: (print and sign in pen) Name of Signatory: Position: Where the answers are not in my/our handwriting they have been checked jointly and/or severally by me/us and are certified as correct. Signature : Dated: (print and sign in pen) Signing of this Proposal Form does not bind the Proposer or Underwriters to complete a contract of Insurance. Subject to the Policy Terms limits and conditions. Form Return Details Please return the completed form to your Insurance Broker For Brokers only, please return this form to P F E W High Street Underwriting Agency - Contractors All Risk Proposal HSUA

6 ANY ADDITIONAL INFORMATION YOU WISH TO PROVIDE High Street Underwriting Agency - Contractors All Risk Proposal HSUA

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