Public & Products Liability Proposal

Transcription

1 P F A.F.S Licence A.C.N Public & Products Liability 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 - Liability General Proposal HSUA

2 YOUR DETAILS 1. Name Commencement date of Insured (Full names of all entities requiring cover including trading names): business 2. Contact Details Business Address: Suburb: State: Postcode: Phone: Fax: Mobile: Website: PERIOD AND LIMITS OF INSURANCE 1. Period of Insurance (a) Insurance cover is needed from: to: 2. Insurance Limits (a) Public Liability $ any one occurrence (b) Products Liability $ annual aggregate (c) Goods in Care, Custody & Control $ (d) Please describe type of 'goods': BUSINESS PARTICULARS 1. Business Description Full description of your Business: 2. Experience (a) Experience of the Principal: years months (b) If you have been in business for less than 3 years, please give details of previous experience: High Street Underwriting Agency - Liability General Proposal HSUA

3 3. Turnover / Payroll (a) (b) (c) (d) Actual turnover for the last 12 months: $ Estimate Annual Turnover for the next 12 months: $ Estimate of annual payroll (including earnings of directors and partners): $ Staff Numbers: 4. Business Operations Outside Australia (a) Do you operate outside Australia? Yes No (b) Location Operations Annual Gross Income 5. Sub-Contractors (a) Do you use sub-contractors? Yes No (b) Estimated Annual Payments $ (c) Nature of work performed: (d) Are sub-contractors required to carry their own liability insurance? Yes No - If 'Yes', to what limit of liability $ (e) Do you always check the Insurance s of sub contractors? Yes No 6. Products (a) Do you manufacture, supply, distribute or sell any products? Yes No (b) If 'Yes' please: (i) Provide product brochures or other relevant documents (ii) Provide further details below: Estimated turnover for Product: Use of Product: next 12 months: (c) Are your Products required to comply with Australian Standards or other Government regulatory requirements? Yes No (d) What quality control procedures are set in place? (e) What tests are carried out on products? (f) Do you maintain records of the origin of all components of your products? Yes No (g) Are any products manufactured for use in aircraft? Yes No High Street Underwriting Agency - Liability General Proposal HSUA

4 (h) Are any products or components or ingredients of products imported? Yes No Product or Components Use of Product or Components Country imported from (i) Do you export products to other countries? Yes No Estimated Annual Gross Product Country Income 7. USA and Canada (a) Have you given Power of Attorney to any person or corporation in the USA or Canada? Yes No (b) Do you have any assets/company located in the USA or Canada? Yes No (c) Do you have any employees or other representatives in the USA or Canada? Yes No (d) Please supply copies of all contracts in relation to exports to the USA or Canada. 8. Contractual Liability (a) Have you entered into any contracts or agreements where you have assumed the liability of others or released others from liability (hold harmless)? Yes No ***Note : This insurance does not cover such liability unless agreed by the Companies. Please provide a copy of such contracts and agreements if cover is required. An extra premium may apply. 9. Use of Certain Machinery / Chemicals etc. (a) Does your business use unregistered vehicles? Yes No (b) Does your business use elevators/escalators? Yes No (c) Does your business use cranes and/or other lifting equipment? Yes No High Street Underwriting Agency - Liability General Proposal HSUA

5 (d) Does your business use pressure vessels and boilers? Yes No (e) Does your business use hazardous chemicals? Yes No Chemical Quantity Details of storage (f) Do you (employees or sub contractors) carry out any hot works? Yes No - If 'Yes', do your safety procedures comply with the Australian Standards? 10. Claims / Insurance History (a) Do you curently have insurance? Yes No - If 'Yes', please advise the name of the holding Underwriter: During the past five years, have you ever had a claim made against you, or (b) are you aware of any incident, accident or prosecution which could lead to a Yes No claim being made against you (whether insured or not)? Date Particulars Cost Name of Insurer (if any) (c) Has any insurer ever declined indemnity for any claim made by you? Yes No (d) Has any insurer declined, refused to renew, cancelled or imposed special Yes No conditions to any policy of insurance held by you? High Street Underwriting Agency - Liability General Proposal HSUA

6 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. Major Exclusions Asbestos, Fines and penalties, Libel and slander (as per wording), Terrorism, Injury to employees of the Proposer, Recall of Products, Watercraft exceeding 8 metres in length, Guarantee of Products, Liability assumed under contracts or agreements (unless agreed), Pollution, Professional indemnity, USA & Canada exposures (unless agreed), Registered vehicles or vehicles that should be registered, Punitive and exemplary damages, 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 info@hsua.com.au P F E Info@hsua.com.au W High Street Underwriting Agency - Liability General Proposal HSUA

7 ANY ADDITIONAL INFORMATION YOU WISH TO PROVIDE High Street Underwriting Agency - Liability General Proposal HSUA