QBE PRODUCT LIABILITY PROPOSAL FORM
|
|
- Jeffrey Walsh
- 8 years ago
- Views:
Transcription
1 QBE PRODUCT LIABILITY PROPOSAL FORM Intermediary: NOTICE TO THE PROPOSED INSURED Your Duty of Disclosure A. Your attention is drawn to your duty of disclosure, as follows: (1) An Insured has a duty to disclosure to the Insurer, before the relevant contract of insurance is entered into, every matter that is known to the Insured being a matter that: (a) the Insured knows to be a matter relevant to the decision of the Insurer whether to accept the risk, and if so, on what terms, or (b) a reasonable person in the circumstances could be expected to know to be a matter so relevant. (2) the duty of disclosure does not require the disclosure of a matter: (a) the diminishes the risk, (b) that is of common knowledge, (c) that the insurer knows or in the ordinary course of his/her business as an Insurer ought to know, or (d) as to which compliance with the duty of disclosure is waived by the Insurer. (3) Where a person: (a) fails to give an answer, or (b) gives an obviously incomplete or irrelevant answer to a question included in a proposal form about a matter, the Insurer shall be deemed to have waived compliance with the duty of disclosure in relation to the matter. B. Non-Disclosure If you fail to comply with your duty of disclosure, we may be entitled to reduce our liability under the contract in respect of a claim or may cancel the contract. If your non disclosure is fraudulent, we may also have the option of avoiding the contact from its beginning If insufficient space on this form, please use an attachment page. 1. The Insured a. Full name of proposed Insured including subsidiaries Company Name Page 1 of 9
2 b. Postal Address c. Full description of your operations and activities. d. Number of years in continuous business 2. Policy Requirement a. Period of Insurance: From / / At noon local standard time To / / At noon local standard time b. Limit of Indemnity: Product liability $ in the aggregate for all Injury and/or Damage during the Period of Insurance c. Deductible Required $ 3. Estimated Payroll (including earnings of principals, directors, partners) Management, Clerical and Sales $ Manufacturing $ Installation / work away from premises $ Payment to contractors and/or sub-contractors $ Others (please specify) $ Total $ No. of Staff 4. Product Information / Estimated Annual Turnover Please give details of all products in respect of which insurance required. a. Description of Product (M) Manufacture (I) Import Page 2 of 9 Total Turnover( $ ) Exports ( $ ) Destination
3 (D) Distribute TOTAL THE PRODUCTS: List of the products manufactured (imported) or goods sold: Please attach any product Brochure (s) and other descriptive documents, Annual Reports or other material if applicable. b. Do you currently or have you in the past been involved in the manufacture, distribution or sale of the following and t o your knowledge are any of the products used or incorporated in: i. Aircraft (Including component Parts), Spacecraft and satellite Yes No ii. Watercraft Yes No iii. Atomic Reactors or Installations Yes No iv. Petro Chemical Installations Yes No v. Ethical Drug Yes No vi. Class 1 Dangerous Group and ammunition Yes No vii. Fertiliser Yes No viii. Pesticides Yes No ix. Fungicide Yes No x. Liquid or gas fuel Yes No xi. Radioactive material or any Yes No xii. Any Product containing asbestos Yes No xiii. Man-made or synthetic mineral fibres (eg. Fibreglass) Yes No If YES please provide details including turnover: Page 3 of 9
4 c. Do You Design parts or compete components for others? Yes No d. Do you Manufacturer to design, formula, plans or specifications of others? Yes No e. If your product range relatively static or changing frequently both in regards to the quantity and any type of products Yes No f. Are you UNABLE to identify the source of supply of every item used in the manufacture of the products? Yes No g. Do you expect to manufacture any new products in the next 12 months? Yes No If answer is Yes to any of the above (c) to (g) please provide details 5. Do you have any overseas representation, office or sales organization? Yes No If YES, please provide details 6. Installation: a. Do you install or apply your own product/s or perform any services? Yes No If YES give details and state whether work is guaranteed: b. What supervision is employed 7. In respect of Exports to the USA and Canada, Please advise: a. Are you represented or do you have any assets within the USA or Canada? Yes No b. Does any one your Power of Attorney within the USA or Canada Yes No c. IS the Importer, Distributor, agent or purchaser insured for Product liability? Yes No d. Are you included as an Insured in such Contracts of Insurance Yes No e. Give Full details (including copies of contracts etc) of all contractual agreement, terms and conditions existing between you and an US/ CANADIAN importer, distributor, agent or purchaser of the Product exported thereto. f. Under what terms are the products exported (eg FOB) g. How long have such product been exported to the USA or Canada Page 4 of 9
5 h. Pollution i. Does your use and storage of all toxic substances comply with all statutory Regulations and By-Laws? Yes No ii. Do any of your trade processes produce toxic waste and other pollutants which have the potential to cause injury to persons or damage to property or otherwise harm the environment? Yes No i. Does your waste disposal or waste storage comply with Government Regulations and By- Laws? Yes No If yes, Please give full details of any chemicals, gases, explosives, radioactive or toxic substances used &/or stored 8. Please provide a list of discontinued products manufactured and/or distributed by you: Yes No If YES, please provide details of reason, type of products and year, etc 9. List the types of consumers to whom products or goods are sold and whether sold direct to public or through Wholesalers, Distributors or Retailers: 10. Raw Materials, Components or Supplies: a. Describe raw materials, components or supplies used: b. Are raw materials, components or supplies imported? Yes No If YES give full details of Manufacturer or Supplier and Country of Origin. 11. Do any of your suppliers contract out of Liability? Yes No If YES give details: 12. Are the finished products: a. Subject to any Local Standards Association or relevant international Codes? Yes No b. Subject to any Statutory or other Regulations? Yes No Page 5 of 9
6 If YES give details and also state whether these are being complied with: 13. Do you a. Impose Conditions of Sale? Yes No b. Make any disclaimers of Liability? Yes No c. Give any guarantee for your products? Yes No If YES give details (please provide copies): 14. Have you ever had to withdraw or recall products from use? Yes No If YES, give details: 15. Do you have re-call procedures in place? Yes No If YES, give details: 16. Are any of the products designed or formulated by your own staff? Yes No If YES, give details: 17. Quality Control: a. What methods of Quality Control are adopted? ie Is each and every product i. Inspected Only? ii. Tested only? b. Are sampling techniques employed? Yes No If YES, state degree of fault tolerated (if any), eg., 2 per 1,000 per hour per batch: c. What tests and/or inspections are made on the samples? d. Are batch samples retained and catalogued? Yes No If so, for how long are they retained and records kept? e. What is the calculated number of defects in relation to output per product? f. What is the maximum allowed by production manager? Page 6 of 9
7 g. What features, if any, are incorporated to ensure that defects are eliminated or reduced or specifications are complied with: Raw materials of the product, h. Can all of your products be identified as having been manufactured by yourself? 18. Containers: How are the products packed eg. Glass, metal, cardboard etc? 19. Labels: a. Do your products carry labels/packaging and/or information sheets, which provide instructions and/or information regarding the correct use or storage and/or warnings of potential hazards? b. Do your labels/packaging and/or information sheets carry instructions in relation to medical treatment and/or remedial treatment/action to be taken in the event of an accident, consumption, or misuse of the product? Has the information or instructions contained on your labels, packaging and/or information sheets been tested and/or checked for accuracy? c. Has the information/instructions contained on your labels, packaging and/or information sheets been checked by a solicitor or lawyer? Yes No 20. Is coverage afforded by any other Policy of Insurance? Yes No 21. Professional Exposure Do you provide any advice, design or specification to third parties (a) For a fee Yes No (no coverage is afforded unless specifically endorsed to the policy) (b) for no fee Yes No Page 7 of 9
8 22. Contractual Liability Coverage for liability assumed under contract or agreement will be limited to lease liability or liability assumed under a warranty of illness or quality as regards your products, or specifically agreed contracts. Please give full details and attach copies of all agreements (other than lease liability) where you assume liability under contract or hold others harmless. Coverage will be provided only if specifically agreed by QBE. Do you assume liability under contract or hold others harmless (other than lease liability)? Yes If Yes, provide full details and attach copies of all agreements (other than lease liability). No 23. History: Have any legal proceedings every been initiated against the proposer in connection with any products or goods sold or services rendered by the proposer or any of its subsidiaries anywhere in the world? Yes No If YES give details 24. Claims and/or Loss Experience After investigation please provide claims experience and/or uninsured loss experience over the last five years for losses and claims that would have been covered under the proposed insurance. Please show claim amount after the application of any excess. Insurance Period No. Claims Reported Amount paid and outstanding Applicable Excess Description Page 8 of 9
9 25. After investigation are there any circumstances of which you are aware a. which could give rise to a claim under the proposed Policy and which are not mentioned above. Yes No b. Is there any additional information or detail of which your are aware and which ay assist the Underwriter to better assess the nature of the risk? Yes No 26. Previous Insurance History After investigation has any proposed insured ever had any: (i) Insurance declined or cancelled? Yes No (ii)renewal refused? Yes No (iii) Special conditions imposed? Yes No (iv) Increased excess imposed? Yes No (v) Claims denied for this class of insurance? Yes No If YES give details: Declaration I declare that to the best of my knowledge and belief the answers given above, documents or papers submitted, represent the true position and that I have not withheld any information material to this proposal. I agree that this proposal and accompanying documents or papers shall form or partly form the basis of the Contract proposed. Signature(s): Date: Title: Page 9 of 9
COMBINED GENERAL LIABILITY POLICY PROPOSAL FORM
COMBINED GENERAL LIABILITY POLICY PROPOSAL FORM Intermediary: This is your proposal for insurance. It will be the basis of any subsequent insurance policy that the Company may issue to you. You are obliged
More informationPublic & Products Liability Proposal Form Standard
Public & Products Liability Proposal Form Standard IMPORTANT NOTICES Your Duty Of Disclosure This Policy is subject to the Insurance Contracts Act 1984. Under that Act you have a duty of disclosure. Before
More informationCombined General Liability Insurance
Combined General Liability Insurance Proposal form Completing the Proposal form 1. This application must be completed in full including all required attachments. 2. If more space is needed to answer a
More informationPublic & Products Liability Proposal Form IMPORTANT NOTES
Public & Products Liability Proposal Form IMPORTANT NOTES Completing this Proposal Form does not mean that you will automatically be granted insurance cover proposed. However, if insurance is granted,
More informationMiramar Broadform Liability Insurance Proposal
Miramar Broadform Liability Insurance Proposal IMPORTANT NOTES YOUR DUTY OF DISCLOSURE Before You enter into a contract of general insurance with an insurer, You have a duty, under the Insurance Contracts
More informationPublic and Products Liability Proposal Form
Public and Products Liability Proposal Form Solution Underwriting Agency Pty Ltd Level 5, 289 Flinders Lane Melbourne, Victoria. Australia 3000 T. 03 9654 6100 F. 03 9654 6200 www.solutionunderwriting.com.au
More informationPROPOSAL FOR PUBLIC AND PRODUCTS LIABILITY INSURANCE
PROPOSAL FOR PUBLIC AND PRODUCTS LIABILITY INSURANCE DUTY OF DISCLOSURE Before you enter into a contract of general insurance with an Insurer, you have a duty, under the Insurance Contracts Act, 1984,
More informationPublic & Products Liability and Professional Indemnity Proposal Property Maintenance Contractors
Public & Products Liability and Professional Indemnity Proposal Property Maintenance Contractors IMPORTANT NOTICES Your Duty Of Disclosure This Policy is subject to the Insurance Contracts Act 1984. Under
More informationProposal Form - Commercial General Liability Insurance
Toll Free Number 1800-209-5846 (1800-209-LTIN) Website www.ltinsurance.com Proposal Form - Commercial General Liability Insurance SMS LTI to 5607058 (56070LT) GUIDELINES TO FILL THE FORM (Information given
More informationQBE FORWARD Cover BROADFORM PUBLIC & PRODUCTS LIABILITY INSURANCE
QBE FORWARD Cover BROADFORM PUBLIC & PRODUCTS LIABILITY INSURANCE for Public Liability for Public & Products Liability FLEXIWRITE Proposal Every forward-looking manager will consider the daunting implications
More informationCommercial Liability Insurance Application
Commercial Liability Insurance Application Name of Applicant: Address: Applicant s Trade or Business: Name, Address & Trade or Business of all Subsidiary Companies: How long has Applicant been in business?
More informationProposal Form - Combined Public and Product Liability Insurance
Toll Free Number 1800-209-5846 (1800-209-LTIN) Website www.ltinsurance.com Proposal Form - Combined Public and Product Liability Insurance SMS LTI to 5607058 (56070LT) GUIDELINES TO FILL THE FORM 1. Please
More informationProposal Public & Products Liability
Proposal Public & Products Liability This proposal must be signed on the declaration page by the insured or a person employed and/or authorised by the insured. This form is not valid if signed by a broker.
More informationCommercial General Liability Application for Insurance
Commercial General Liability Application for Insurance This proposal for insurance will be the basis of any subsequent insurance policy that we issue to you. It is essential that you answer fully and accurately
More informationCombined General Liability
Combined General Liability Proposal form Policy number Intermediary Completion notes Please read the following before completing this document. Answer all questions in full. If you need extra space, attach
More informationPHARMASURE PUBLIC AND PRODUCT LIABILITY APPLICATION FORM Form A ( Complementary, OTC & Cosmetics)
PharmaSure Insurance Services Suite 202, 103 Miller Street, North Sydney NSW 2060 Australia Postal Address: PO Box 1678 North Sydney NSW 2059 Australia Phone: +612 9929 9877 Fax: +612 9929 9811 Email:
More informationPublic and Products Liability insurance proposal.
Public and Products Liability insurance proposal. Liability Intermediaries Important notices. Policy Number Please read this section before completing this proposal Your Duty of Disclosure: You have a
More informationPublic & Products Liability Proposal
P 1800 096 829 F 1800 096 680 A.F.S Licence 244370 A.C.N 096 939 169 Public & Products Liability Proposal IMPORTANT NOTICE This Proposal Form must be typed, or completed in ink and signed and dated by
More informationProduct Liability Insurance Proposal Form
Product Liability Insurance Proposal Form Notes: Statement pursuant to Section 25(5) of the Insurance Act (Cap 142) or any amendments thereof: you are to disclose in the application, fully and faithfully,
More informationProposal Form for Marine Trades Public & Products Liability Application
OCEANIC MARINE RISKS PTY LTD ABN 82 010 671 851 AFSL 238271 Call Us 07 4946 7555 Proposal Form for Marine Trades Public & Products Liability Application YOUR DUTY OF DISCLOSURE Before you enter into a
More informationliability insurance application liability Insurer CGU Insurance Limited ABN 27 004 478 371 An IAG Company
liability insurance application liability Insurer CGU Insurance Limited ABN 27 004 478 371 An IAG Company Extract from the Insurance Contracts Act 1984 Under the terms of the Act We must advise You about
More informationPROPOSAL FORM FOR PRODUCT LIABILITY INSURANCE
PROPOSAL FORM FOR PRODUCT LIABILITY INSURANCE 1. Name of the Proposer (in full) Names of the Subsidiaries & Associate Cos. (in full) 2. Registered Address of the Proposer. 3. Business address of the proposer.
More informationBuilders Property owners Golf clubs Theme parks Attractions Amusement arcades Textiles Warehouses Precision engineering Mechanics Manufacturing
Builders Property owners Golf clubs Theme parks Attractions Amusement arcades Textiles Warehouses Precision engineering Mechanics Manufacturing Combined Liability Proposal Form General Trades Cleaning
More informationPublic Liability Insurance
Public Liability Insurance THE INSURED Name of Insured Are you registered for GST? What is your ABN? Have you claimed or intend to claim an input tax credit on the GST component of the premium applicable
More informationCOMPREHENSIVE GENERAL LIABILITY INSURANCE Proposal Form Operations and Contractual Liability Coverage on a claims made basis
COMPREHENSIVE GENERAL LIABILITY INSURANCE Proposal Form Operations and Contractual Liability Coverage on a claims made basis This proposal is to be completed by the proposer or an authorised officer of
More informationPublic & Products Liability Proposal Form Go Kart Centres
Public & Products Liability Proposal Form Go Kart Centres IMPORTANT NOTICES Your Duty Of Disclosure This Policy is subject to the Insurance Contracts Act 1984. Under that Act you have a duty of disclosure.
More informationTyre Retail / Wholesale Proposal Public & Products Liability
Tyre Retail / Wholesale Proposal Public & Products Liability This form must be signed by the insured/proposer or a person employed and/or authorised by the insured/proposer. When completing the form, if
More informationPROPOSAL FOR ERRORS AND OMISSIONS INSURANCE
PROPOSAL FOR ERRORS AND OMISSIONS INSURANCE DUTY OF DISCLOSURE Before you enter into a contract of general insurance with an Insurer, you have a duty, under the Insurance Contracts Act, 1984, to disclose
More informationRENEWABLE ENERGY MANUFACTURERS LIABILITY INSURANCE PROPOSAL FORM
RENEWABLE ENERGY MANUFACTURERS LIABILITY INSURANCE PROPOSAL FORM Introduction The information you provide on this proposal is vital to Underwriters consideration of the relative risks associated with your
More informationPRODUCTS LIABILITY SUPPLEMENTAL APPLICATION (Use additional sheets when necessary)
PRODUCTS LIABILITY SUPPLEMENTAL APPLICATION (Use additional sheets when necessary) 1. APPLICANT a) Full Name (and list all subsidiary Companies) Proposed Effective Date: b) Mailing Address c) Location(s)
More informationProposal Form. Construction Industry Consultants Professional Indemnity
Proposal Form Construction Industry Consultants Professional Indemnity Important Notices Please read these notices before completing the Proposal Form. Your Duty of Disclosure Before you enter into a contract
More informationPROPOSAL FORM FOR PRODUCT LIABILITY INSURANCE PRODUCT CODE: 3302
PROPOSAL FORM FOR PRODUCT LIABILITY INSURANCE PRODUCT CODE: 3302 Important: this proposal for insurance will be the basis of any subsequent insurance policy that we issue to you. It is essential that you
More informationCommercial General Liability Insurance Proposal Form. Public Liability Exposures
Commercial General Liability Insurance Proposal Form General Data 1. Name of Proposer in full: 2. Address: 3. Description of Business: 4. How long established? Public Liability Exposures 1. Description
More informationBusiness Insurance Preparation - A Practical Application
PRODUCTS LIABILITY INSURANCE QUESTIONNAIRE YOU ARE TO DISCLOSE IN THIS FORM FULLY AND FAITHFULLY ALL FACTS WHICH YOU KNOW OR OUGHT TO KNOW, OTHERWISE YOU MAY RECEIVE NOTHING FROM THIS INSURANCE CONTRACT
More informationPUBLIC & PRODUCTS LIABILITY PROPOSAL FORM IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS PROPOSAL
PUBLIC & PRODUCTS LIABILITY PROPOSAL FORM IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS PROPOSAL A. Obtaining a Quotation To minimise delays in obtaining a quotation
More informationGeneral Liability Insurance GROUP PTY LTD. Proposal Form. RSM GROUP Pty Ltd - Wholesale Broking
GROUP PTY LTD General Liability Insurance Proposal Form RSM GROUP Pty Ltd - Wholesale Broking ABN 40 006 361 226 AFS Licence No. 239631 380-382 Canterbury Road, Surrey Hills Vic 3127 Private Bag 4000 Surrey
More informationCOMMERCIAL PROPERTY/LIABILITY APPLICATION
COMMERCIAL PROPERTY/LIABILITY APPLICATION APPLICANT Name of Insured: Mailing Address: Risk Address: Description of Operations Occupancy of Others of Year in Business Name(s) and Address(es) of Mortgagee(s)
More informationLIABILITY INSURANCE SUMMARY OF COVER
LIABILITY INSURANCE SUMMARY OF COVER This gives only a summary of the cover provided and it does not give details of all the terms, conditions and exclusions. A full policy wording is available on request.
More informationAPPLICATION FOR UMBRELLA & EXCESS LIABILITY INSURANCE
APPLICATION FOR UMBRELLA & EXCESS LIABILITY INSURANCE For purposes of the Insurance Companies Act (Canada), this document was issued in the course of Liberty Mutual Insurance Company s insurance business
More informationBUSINESS, EXECUTIVE, LIFE COACHES PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM
BUSINESS, EXECUTIVE, LIFE COACHES PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT FACTS RELATING TO THIS PROPOSAL FORM The Purpose of this Proposal Form is to set out all relevant information
More informationRENEWABLE ENERGY CONTRACTORS LIABILITY INSURANCE PROPOSAL FORM
Introduction RENEWABLE ENERGY CONTRACTORS LIABILITY INSURANCE PROPOSAL FORM The information you provide on this proposal is vital to Underwriters consideration of the relative risks associated with your
More informationCommercial General Liability Insurance Proposal Form
IMPORTANT NOTE Commercial General Liability Insurance Proposal Form Certain Underwriters at Lloyd s and/or Companies (Insurers) acting through their agent International Underwriting Agencies Ltd ( IUA
More informationProduct Liability Insurance
Product Liability Insurance Proposal Form ADNIC is a Public Joint Stock Company incorporated in the United Arab Emirates by Law No. (4) of 1972, and it is governed by the provisions of the UAE Federal
More informationSECURITY CONTRACTORS APPLICATION FORM
SECURITY CONTRACTORS APPLICATION FORM Epsilon Underwriting Agencies Pty Limited Epsilon Insurance Broking Services Pty Limited T/as Epsilon Underwriting Agencies ( Epsilon ) is effecting this cover as
More informationBUSINESS LIABILITY APPLICATION
BUSINESS LIABILITY APPLICATION EPSILON UNDERWRITING AGENCIES PTY LIMITED Epsilon Insurance Broking Services Pty Limited T/as Epsilon Underwriting Agencies ( Epsilon ) is effecting this cover as Agent for
More informationAPPLICATION FOR SPECIFIED PRODUCTS AND COMPLETED OPERATIONS LIABILITY INSURANCE
Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Associated International Insurance Company APPLICATION FOR SPECIFIED
More informationProposal Form Professional Indemnity Insurance (IT Professions)
Proposal Form Professional Indemnity Insurance (IT Professions) AXA INSURANCE SINGAPORE PTE LTD 8 Shenton Way, #27-01 AXA Tower Singapore 068811 Customer Service Centre #B1-01 (65) 6338 7288 (65) 6338
More informationQ U E S T I O N N A I R E GENERAL BUSINESS AND PRODUCTS LIABILITY INSURANCE AGENCY: 1. Proposer s name in full. 2. Tel. No. Telex No Fax No.
National Union / Fire Insurance Co of Pittsburgh, PA 119, 151 24,.:+ 30 210-8127600, fax:+30 210-8027189 Y. : 42, 57001,. 2310 474 999, Fax 2310 474 980 Info.Gr@chartisinsurance.com url: www.chartisinsurance.gr
More informationPUBLIC & PRODUCTS LIABILITY RENEWAL DECLARATION
PUBLIC & PRODUCTS LIABILITY RENEWAL DECLARATION IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS RENEWAL DECLARATION A. Obtaining a Quotation To minimise delays in obtaining
More informationARCHITECTS, ENGINEERS, SURVEYORS & CONSTRUCTION INDUSTRIES PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM
Australian Indemnity ARCHITECTS, ENGINEERS, SURVEYORS & CONSTRUCTION INDUSTRIES PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT FACTS RELATING TO THIS PROPOSAL FORM The Purpose of this Proposal
More informationLiabilities Proposal Form
Liabilities Proposal Form www.towergate.co.uk IMPORTANT INFORMATION Your insurance contract will be prepared based on the information supplied by you, which is shown on this Proposal. To the best of your
More informationLIBERTY INTERNATIONAL UNDERWRITERS CANADA (a division of Liberty Mutual Insurance Company hereinafter called the Company)
LIBERTY INTERNATIONAL UNDERWRITERS CANADA (a division of Liberty Mutual Insurance Company hereinafter called the Company) INSURANCE AGENTS AND BROKERS PROFESSIONAL LIABILITY APPLICATION FOR INSURANCE THIS
More informationProfessional Trainers, Licensing Assessment and Consultancy Services Professional Indemnity and Public Liability Insurance Proposal Form
Tranznet Association Inc Arranges the insurance IMPORTANT INFORMATION Professional Trainers, Licensing Assessment and Consultancy Services Professional Indemnity and Public Liability Insurance Proposal
More informationIMPORTANT NOTICES: Your duty, however, does not require disclosure of matter:
IMPORTANT NOTICES: CLAIMS MADE POLICY This Proposal is for a policy issued by ProRisk on a claims made and notified basis. This means that the policy only covers claims first made against you during the
More informationType Description of Activity Estimates
PROPOSAL FOR PUBLIC AND PRODUCT LIABILITY INSURANCE AGENCY : SECTION 1 - DESCRIPTION OF TRADE 1 Proposer's name in full : 2 Tel. No. Telex No. Fax No. 3 Postal Address : 4 Country of Operations : 5 Business
More informationPROPASAL FROM FOR PUBLIC LIABILITY INSURANCE (For Industrial Risks and Storage Risks)
PROPASAL FROM FOR PUBLIC LIABILITY INSURANCE (For Industrial Risks and Storage Risks) LIABILITY OF THE COMPANY DOES NOT COMMENCE UNTIL THE PROPOSAL HAS BEEN ACCEPTED AND THE PREMIUM PAID THE TERRITORIAL
More informationAlarm Installation, Servicing, Monitoring or Repair General Liability Application
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258 Scottsdale Indemnity Company Home Office: One Nationwide
More informationBUSINESS PACKAGE PROPOSAL
BUSINESS PACKAGE PROPOSAL RM Insurance Company (PRIVATE) LIMITED RM 317A INDEX SECTION S. PAGES 1 Fire 1 2 Business Interruption 2 3 3 All Risks 3 4 Theft 4 5 Money 4 6 Glass 5 7 Goods in Transit 5 8 Liability
More information1. Company Information Company Name:... Postal Address:... Post Code:... Website Address:... Email Address... Other Trading Address:...
Proposal Form Information & Communication Technology Professional Indemnity Important Notices Please read these notices before completing the Proposal Form. Your Duty of Disclosure Before you enter into
More informationPROPOSAL FORM. Fleet Heavy Motor Vehicle Insurance. Page 1 of 7. Important Notices Please read these Important Notices before completing the Proposal.
PROPOSAL FORM Fleet Heavy Motor Vehicle Insurance Important Notices Please read these Important Notices before completing the Proposal. Duty of Disclosure Under the Insurance Contracts Act 1984 (the Act),
More informationAlarm Installation, Servicing, Monitoring or Repair General Liability Application
Scottsdale Insurance Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Indemnity Company Home Office: One Nationwide Plaza Columbus, Ohio 43215 Scottsdale Surplus Lines Insurance
More informationCommercial General Application (Manufacturing/Wholesale/Retail)
Commercial General Application (Manufacturing/Wholesale/Retail) Applicant Information Named Insured: Address of Insured: Desired Effective and Expiration Dates: Broker Information Brokerage Name: Address
More informationPROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM
PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT FACTS RELATING TO THIS PROPOSAL FORM The Purpose of this Proposal Form is to set out all relevant information for your adviser to submit on your
More informationPRODUCT LIABILITY SUPPLEMENTAL APPLICATION
Note: This application must be completed in addition to the ACORD Applicant Information Section and the Commercial General Liability Application. Please attach the following information about your products
More informationProfessional Indemnity Insurance
QBE Insurance (Australia) Limited ABN 78 003 191 035 Professional Indemnity Insurance Application Form Pool Safety Inspectors Notice to the Applicant This notice must be read before you complete the Application
More informationQBE Trade Credit Trade Credit Insurance proposal form
QBE Trade Credit Trade Credit Insurance proposal form QBE European Operations Please read the following information carefully This document sets out the important information that you, or your insurance
More informationPROPOSAL FORM FOR PRODUCT LIABILITY INSURANCE
PROPOSAL FORM FOR PRODUCT LIABILITY INSURANCE ------------------------------------------------------------------------------------------------------------------ Liability of the Company does not commence
More informationMARINE COMMERCIAL LIABILITY POLICY APPLICATION
Page 1 of 5 MARINE COMMERCIAL LIABILITY POLICY APPLICATION A. GENERAL INFORMATION DATE A. Account Name Address: City / State / Country: Website: B. Insurance Agent or Broker: Address: City / State / Country:
More informationWorkers compensation exposure checklist
PIA Doc. No. 90583 Workers compensation exposure checklist To contact PIA for more information, or to request a QuickSource document index, contact: phone: (800) 424-4244 fax: (888) 225-6935 email: resourcecenter@pia.org
More informationCOMMERCIAL ASSET FINANCE BROKERS ASSOCIATION OF AUSTRALIA LIMITED PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM
COMMERCIAL ASSET FINANCE BROKERS ASSOCIATION OF AUSTRALIA LIMITED PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT FACTS RELATING TO THIS PROPOSAL FORM The Purpose of this Proposal Form is to set
More informationProfessional Indemnity Proposal form
Important Information Please read this first Professional Indemnity Proposal form Important facts relating to this proposal form You should read the following advice before proceeding to complete this
More information7. Do you perform any out of state work?... If yes, in what states and provide details of work performed
Applicant s Name* (*If more than one entity, attach separate sheet with description of each entity s operations, relationship to each other and ownership.) Contractors Application Agent Applicant Mailing
More informationProposal Form. BusinessGuard Insurance Brokers Professional Liability Insurance
BusinessGuard Insurance Brokers Professional Liability Insurance BusinessGuard Insurance Brokers Professional Liability Insurance This policy is issued by AIG Australia Limited on a claims-made and notified
More informationShip Repairers Combined Liability Insurance Proposal
Ship Repairers Combined Liability Insurance Proposal 1 Proposer Full name of proposer (incl company and trading name): 2. Proposers postal and physical address: 3 Period & Limit of Liability Cover requested
More informationlabour force professional liability insurance
labour force professional liability insurance application form Notices 1. Intermediary Acting as an Agent for Insurer In effecting this contract of insurance, Lawsons Underwriting Australasia Ltd ABN 35
More informationEntertainment & Event Liability Insurance Proposal
Intermediary Date / / Contact Name Phone ( ) Period of Insurance to at 4.00pm INSURED DETAILS Insured Name / ABN (Full details required, inc. Trading Name if Applicable) ABN: Address / Situation Description
More informationCombined Liability Roofers and Scaffolders Proposal Form
BDB (UK) Limited 40 Lime Street, London EC3M 7AW Combined Liability Roofers and Scaffolders Proposal Form This proposal form must be completed, signed and dated by a partner, principal or director of the
More informationPUBLIC & PRODUCTS LIABILITY PROPOSAL FORM IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS PROPOSAL
PUBLIC & PRODUCTS LIABILITY PROPOSAL FORM IMPORTANT INFORMATION: PLEASE READ THE FOLLOWING INFORMATION BEFORE COMPLETING THIS PROPOSAL A. Obtaining a Quotation To minimise delays in obtaining a quotation
More informationCHILDCARE PROPERTY OWNERS INSURANCE APPLICATION FORM
CHILDCARE PROPERTY OWNERS INSURANCE APPLICATION FORM Public & Products Liability and Professional Indemnity Insurance and Property Insurance. IMPORTANT NOTICE: PLEASE READ & RETAIN IN YOUR FILE This is
More informationProfessional Indemnity Proposal Form. for. Information Technology Consultants
Professional Indemnity Proposal Form for Information Technology Consultants Address: 5/3352 Pacific Highway Postal: PO Box 976 Springwood QLD 4127 Springwood QLD 4127 Phone: 07 3387 2800 Fax: 07 3208 2200
More informationAustralian Institute of Professional Photography photographic insurance application form
Australian Institute of Professional Photography Please Return the Completed Application to: Marsh Pty Ltd Consumer Professional Photographers Insurance GPO Box 1229, Melbourne Vic 3001 Telephone: 1300
More informationACCOUNTANTS, BOOKKEEPERS & RELATED PROFESSIONS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM
ACCOUNTANTS, BOOKKEEPERS & RELATED PROFESSIONS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT FACTS RELATING TO THIS PROPOSAL FORM The Purpose of this Proposal Form is to set out all relevant
More informationPRODUCTS LIABILITY INSURANCE APPLICATION
HOW TO COMPLETE THIS FORM PRODUCTS LIABILITY INSURANCE APPLICATION To complete this form, you must be a principal, partner, or director of the applicant firm and should make all the necessary inquiries
More informationProfessional Trainers, Licensing Assessment and Consultancy Services Professional Indemnity and Public Liability Insurance Proposal Form
Tranznet Association Inc Arranges the insurance IMPORTANT INFORMATION Professional Trainers, Licensing Assessment and Consultancy Services Professional Indemnity and Public Liability Insurance Proposal
More informationlabour force professional liability insurance
labour force professional liability insurance application form Notices 1. Intermediary Acting as an Agent for Insurer In effecting this contract of insurance, Lawsons Underwriting Australasia Ltd ABN 35
More informationQBE PROFESSIONAL LIABILITY. Miscellaneous Risks INSURANCE PROPOSAL PROPOSAL
QBE PROFESSIONAL LIABILITY Miscellaneous Risks INSURANCE PROPOSAL PROPOSAL Professional Indemnity Insurance tice to the Proposed Insured This notice must be read before you complete the proposal form.
More informationTransportation Insurance
Transportation Insurance Proposal form Completing the Proposal form 1. This application must be completed in full including all required attachments. 2. If more space is needed to answer a question, please
More informationProfessional Indemnity Insurance Proposal.
ProJuris Professional Indemnity Professional Indemnity Insurance Proposal. Important information What is a proposal? This proposal tells us information, which we need to know in order to decide whether
More informationProposal Form. Information Technology Combined Professional and Public & Technology Products Liability. Page 1 of 13
Information Technology Combined Professional and Public & Technology Products Liability Page 1 of 13 Information Technology Combined Professional and Public & Technology Products Liability IMPORTANT NOTICE
More informationAsbestos Contractors Pollution Liability Insurance Proposal
Asbestos Contractors Pollution Liability Insurance Proposal American Home Assurance Company ABN 67 007 483 267 AFSL 230903 Trading as AIG Australia (Incorporated with limited liability in the USA) A Member
More informationAction Insurance Brokers Pty Ltd Public Liability Insurance Proposal
Action Insurance Brokers Pty Ltd Public Liability Insurance Proposal Period of Insurance to Day Month Year Day Month Year at 4.00pm Name of Insured (inc. all subsidiary companies) Postal Address Description
More informationTOURISM LIABILITY APPLICATION FORM TOUR OPERATORS
BUSINESS DETAILS TOURISM LIABILITY APPLICATION FORM TOUR OPERATORS Legal Entity: Trading Name: ABN: Number of years you have operated this business: (If less than 3 years please provide details or previous
More information6. WARNING BY BUYER. BUYER shall give warning of any possible hazard to any person or persons to whom BUYER resells, gives or delivers the Property
TERMS AND CONDITIONS FOR ONLINE TRANSACTIONS TO PURCHASE GP PROPERTY (VIA GOINDUSTRY DOVEBID) By submitting a bid to purchase the Property (as defined below), BUYER (as defined below) agrees that the following
More informationMISCELLANEOUS PROFESSIONAL LIABILITY / GENERAL LIABILITY APPLICATION
MISCELLANEOUS PROFESSIONAL LIABILITY / GENERAL LIABILITY APPLICATION COVERAGE PART A PROFESSIONAL LIABILITY INSURANCE COVERAGE THIS APPLICATION IS FOR A CLAIMS MADE INSURANCE POLICY Please read your policy
More informationProfessional Indemnity Insurance Proposal Form for the Horticulture Industry
Professional Indemnity Insurance Proposal Form for the Horticulture Industry Important Notices Claims Made Insurance This is a proposal for a Claims Made policy of insurance. This means that the policy
More informationArchitects and Engineers Professional Liability Proposal Form
Notice:Statement pursuant to Section 25(5) of the Insurance Act (Cap 142) or any amendments thereof; You are to disclose in this application, fully and faithfully, all the facts which you know or ought
More information1. APPLICANT S DETAILS 2. PLEASE COMPLETE THIS SECTION FOR PUBLIC LIABILITY
PUBLIC LIABILITY/PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM FOR SWIM TEACHER/COACH PLEASE USE BLOCK LETTERS l ALL SECTIONS MUST ME COMPLETED Please ensure you have read and understood the Important
More informationQBE Professional Indemnity Proposal Form Single Project Professional Indemnity
Notice to the Proposed Insured QBE Professional Indemnity Proposal Form Your duty of disclosure If a proposer does not fully and faithfully give the facts as he knows them or ought to know them, he may
More informationENTERTAINMENT & EVENTS LIABILITY INSURANCE
Arena Underwriting Pty Ltd ABN: 26 125 869 481 AFS: 317617 Suite 8, 12 Alma Road, New Lambton NSW 2305 Tel: 02 4952 4477 Fax: 02 4915 5376 www.arenaunderwriting.com.au ENTERTAINMENT & EVENTS LIABILITY
More informationCOMBINED LIABILITY INSURANCE PROPOSAL FORM
COMPANY DETAILS 1. Proposer s Full Name 2. Legal Trading Name (Name to appear on policy documentation) 3. Occupation / Business / Trade Description (please detail all activities) 4. Address Postcode 5.
More information