Public and Products Liability Proposal Form

Size: px
Start display at page:

Download "Public and Products Liability Proposal Form"

Transcription

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

Public & Products Liability Proposal Form Standard

Public & 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 information

Public & Products Liability and Professional Indemnity Proposal Property Maintenance Contractors

Public & 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 information

Miramar Broadform Liability Insurance Proposal

Miramar 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 information

Public & Products Liability Proposal Form IMPORTANT NOTES

Public & 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 information

Combined General Liability Insurance

Combined 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 information

PHARMASURE PUBLIC AND PRODUCT LIABILITY APPLICATION FORM Form A ( Complementary, OTC & Cosmetics)

PHARMASURE 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 information

Proposal Public & Products Liability

Proposal 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 information

PROPOSAL FOR PUBLIC AND PRODUCTS LIABILITY INSURANCE

PROPOSAL 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 information

Professional Indemnity Proposal

Professional Indemnity Proposal Professional Indemnity Proposal 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 you take out insurance

More information

PUBLIC & 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 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 information

sp rts Sports Coaching & Clinics Insurance Application Form Underwriting Australia Sports Leisure Licensed Clubs

sp rts Sports Coaching & Clinics Insurance Application Form Underwriting Australia Sports Leisure Licensed Clubs sp rts Underwriting Australia Insurance Application Form Sports Leisure Licensed Clubs Please use this application for occupations relating to the including: Sports Clinics Sports Coaches School Sports

More information

PUBLIC & 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 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 information

COMBINED GENERAL LIABILITY POLICY PROPOSAL FORM

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 information

Public & Products Liability Proposal Form Go Kart Centres

Public & 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 information

1. NAME OF FIRM TO BE INSURED 2. ADDRESS OF FIRM 3. THE FIRM. (please include full names of all entities to be insured) Phone ( ) Email

1. NAME OF FIRM TO BE INSURED 2. ADDRESS OF FIRM 3. THE FIRM. (please include full names of all entities to be insured) Phone ( ) Email SURA Professional Risks Level 13 / 141 Walker St North Sydney NSW 2060 P O BOX 1813 North Sydney NSW 2059 Telephone. 02 9930 9500 Facsimile. 02 9930 9501 sura.com.au MISCELLANEOUS PROFESSIONAL INDEMNITY

More information

Public & Products Liability Proposal

Public & 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 information

Professional Indemnity Insurance and optional Public & Products Liability

Professional Indemnity Insurance and optional Public & Products Liability Advantedge Members (Incorporating PLAN, FAST and CHOICE Members) Professional Indemnity Insurance and optional Public & Products Liability Proposal form 2014-2015 Please return completed proposal form

More information

Public and Products Liability insurance proposal.

Public 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 information

Eligibility Application Form RBUA Builder Warranty Insurance (South Australia and Western Australia)

Eligibility Application Form RBUA Builder Warranty Insurance (South Australia and Western Australia) Eligibility Application Form RBUA Builder Warranty Insurance (South Australia and Western Australia) IMPORTANT NOTICES About Great Lakes Australia Great Lakes Reinsurance (UK) SE (ARBN 127 740 532, ABN

More information

General Liability Insurance GROUP PTY LTD. Proposal Form. RSM GROUP Pty Ltd - Wholesale Broking

General 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 information

Combined General Liability

Combined 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 information

4. DETAILS OF THE PRINCIPAL(S) OF THE FIRM How Long Practicing as Partner/Director

4. DETAILS OF THE PRINCIPAL(S) OF THE FIRM How Long Practicing as Partner/Director SURA Professional Risks Level 13 / 141 Walker St North Sydney NSW 2060 P O BOX 1813 North Sydney NSW 2059 Telephone. 02 9930 9500 Facsimile. 02 9930 9501 sura.com.au FINANCIAL PLANNERS PROFESSIONAL INDEMNITY

More information

QBE PRODUCT LIABILITY PROPOSAL FORM

QBE PRODUCT LIABILITY PROPOSAL FORM 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

More information

Tyre Retail / Wholesale Proposal Public & Products Liability

Tyre 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 information

Public Liability Insurance

Public 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 information

LABOUR FORCE PROFESSIONAL LIABILITY INSURANCE PROPOSAL FORM

LABOUR FORCE PROFESSIONAL LIABILITY INSURANCE PROPOSAL FORM SURA LABOUR HIRE PTY LTD SUITE 1.04 29 31 LEXINGTON DRIVE BELLA VISTA NSW 2153 TELEPHONE. 02 9672 6088 SURA.COM.AU LABOUR FORCE PROFESSIONAL LIABILITY INSURANCE PROPOSAL FORM IMPORTANT NOTICES The information

More information

ENTERTAINMENT & EVENTS LIABILITY INSURANCE

ENTERTAINMENT & 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 information

COMBINED GENERAL & PRODUCTS LIABILITY INSURANCE EQUINE TRAINER AND COACH PROPOSAL

COMBINED GENERAL & PRODUCTS LIABILITY INSURANCE EQUINE TRAINER AND COACH PROPOSAL COMBINED GENERAL & PRODUCTS LIABILITY INSURANCE EQUINE TRAINER AND COACH PROPOSAL General Insured Name (including individual and any registered business name): Postal Address: Telephone No. Business Mobile

More information

PUBLIC & PRODUCTS LIABILITY RENEWAL DECLARATION

PUBLIC & 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 information

ACE Insurance Limited ELITE II PROFESSIONAL INDEMNITY INSURANCE POLICY

ACE Insurance Limited ELITE II PROFESSIONAL INDEMNITY INSURANCE POLICY ELITE II PROFESSIONAL INDEMNITY INSURANCE POLICY Renewal Proposal Form - Miscellaneous ABN 23 001 642 020 AFSL 239687 Page 1 of 8 ACE ELITE II PROFESSIONAL INDEMNITY INSURANCE RENEWAL PROPOSAL FORM Miscellaneous

More information

Australian Institute of Professional Photography photographic insurance application form

Australian 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 information

Builders Warranty Claim Form

Builders Warranty Claim Form Builders Warranty Claim Form IMPORTANT NOTICES About the Insurer This insurance is underwritten by Great Lakes Reinsurance (UK) SE (ARBN 127 740 532, ABN 18 964 580 576, AFSL 318603) trading as Great Lakes

More information

4. DETAILS OF THE PRINCIPAL(S) OF THE FIRM How Long Practicing as Partner/Director

4. DETAILS OF THE PRINCIPAL(S) OF THE FIRM How Long Practicing as Partner/Director SURA Professional Risks Level 13 / 141 Walker St North Sydney NSW 2060 P O BOX 1813 North Sydney NSW 2059 Telephone. 02 9930 9500 Facsimile. 02 9930 9501 sura.com.au ACCOUNTANTS PROFESSIONAL INDEMNITY

More information

Proposal Form. Architects Professional Indemnity

Proposal Form. Architects Professional Indemnity Proposal Form Architects Professional Indemnity Important Notices Please read these notices before completing the Proposal Form. Your Duty of Disclosure Before you enter into a contract of general insurance

More information

Proposal Form. Construction Industry Consultants Professional Indemnity

Proposal 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 information

JUA Underwriting Agency Pty Ltd

JUA Underwriting Agency Pty Ltd JUA Underwriting Agency Pty Ltd Engineers & Architects Professional Indemnity Proposal Form Please answer every question fully, incomplete answers will not be accepted, and may result in a delay in terms

More information

liability 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 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 information

1. Company Information Company Name:... Postal Address:... Post Code:... Website Address:... Email Address... Other Trading Address:...

1. 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 information

Professional Indemnity Proposal Form

Professional Indemnity Proposal Form Professional Indemnity Proposal Form BuildSafe Insurance Brokers Pty Ltd ABN 84 109 623 976 AFSL 279367 5 Peninsula Boulevard, Seaford, Vic. 3198 Postal: P. O. Box 2294 Seaford, Vic. 3198 Phone: 1300 763

More information

COMBINED GENERAL & PRODUCTS LIABILITY INSURANCE ADVENTURE ACTIVITIES PROPOSAL

COMBINED GENERAL & PRODUCTS LIABILITY INSURANCE ADVENTURE ACTIVITIES PROPOSAL COMBINED GENERAL & PRODUCTS LIABILITY INSURANCE ADVENTURE ACTIVITIES PROPOSAL General Insured Name (business/organisation): Contact Name: Postal Address: Telephone No. Business Mobile Email: Website: Brief

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

PROFESSIONAL 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 information

SECURITY CONTRACTORS APPLICATION FORM

SECURITY 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 information

JUA Underwriting Agency Pty Ltd

JUA Underwriting Agency Pty Ltd JUA Underwriting Agency Pty Ltd Valuers Professional Indemnity Proposal Form Please answer every question fully, incomplete answers will not be accepted, and may result in a delay in terms being issued

More information

IMPORTANT INFORMATION

IMPORTANT INFORMATION IMPORTANT INFORMATION Please read these notices before completing the Proposal. Policy This Policy is an important document and should be kept in a safe place. Please read it carefully so that you understand

More information

mayhave occurred during the period of insurance; Avoid the contract from its beginning, if your non-disclosure fraudulent

mayhave occurred during the period of insurance; Avoid the contract from its beginning, if your non-disclosure fraudulent Arena Underwriting Pty Ltd ABN: 26 125 869 481 AFSL: 317617 Suite 8, 12 Alma Road, New Lambn NSW 2305 Tel: 02 4952 4477 Fax: 02 4915 5376 www.arenaunderwriting.com.au PUBLIC & PRODUCTS VOLUNTARY LIABILITY

More information

Professional Indemnity Proposal Form. for. Accountants. Address: 5/3352 Pacific Highway Postal: PO Box 976. Springwood QLD 4127 Springwood QLD 4127

Professional Indemnity Proposal Form. for. Accountants. Address: 5/3352 Pacific Highway Postal: PO Box 976. Springwood QLD 4127 Springwood QLD 4127 Professional Indemnity Proposal Form for Accountants Address: 5/3352 Pacific Highway Postal: PO Box 976 Springwood QLD 4127 Springwood QLD 4127 Phone: 07 3387 2800 Fax: 07 3208 2200 Email: pidirect@pidirect.com.au

More information

Calliden Construction Work and Legal Liability

Calliden Construction Work and Legal Liability Calliden Construction Work and Legal Liability Insurance Proposal Important tices You must read the tices below. If you have any questions please contact your insurance adviser direct or our office. Visit

More information

COMMERCIAL 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 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 information

DAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM IMPORTANT NOTICES

DAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM IMPORTANT NOTICES DAWES MOTOR INSURANCE MOTOR VEHICLE CLAIM FORM PO Box 2717 Taren Point NSW 2229 Telephone: 1300 188 299 Facsimile: 1300 662 215 Email: claims@dawes.com.au www.dawes.com.au Before completing this claim

More information

Annual Contract Works & General Liability Quote/Proposal Form

Annual Contract Works & General Liability Quote/Proposal Form Annual Contract Works & General Liability Quote/Proposal Form Broker or dealer details Company Name Phone Email Page 1 of 6 Insured details Name of Insured Registered Business address Suburb State Postcode

More information

IMPORTANT NOTICES: Your duty, however, does not require disclosure of matter:

IMPORTANT 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 information

PROPOSAL FOR ERRORS AND OMISSIONS INSURANCE

PROPOSAL 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 information

Engineers, Architects, Surveyors and Relation Professions

Engineers, Architects, Surveyors and Relation Professions Application Form Professional Indemnity Insurance Send quotation requests to: Email: distribution@breezeuw.com.au Phone: 1300 556 826 Engineers, Architects, Surveyors and Relation Professions IMPORTANT

More information

Professional Indemnity Insurance Proposal Form Miscellaneous

Professional Indemnity Insurance Proposal Form Miscellaneous Commercial & General Insurance Brokers (Aust) Pty Ltd Suite 4, 1016 Doncaster Road Doncaster East Victoria 3109 Phone: 1300 764 244 Fax: 03 8841 4299 Email: pi@cgib.com.au Web: www.cgib.com.au AFS License:

More information

Business Insurance Proposal

Business Insurance Proposal Business Insurance Proposal Important Notices You must read the notices below. If you have any questions please contact GWS Genco Group (AFSL No. 231210) Duty of Disclosure This Policy is subject to the

More information

Professional Indemnity Insurance Proposal Form for the Horticulture Industry

Professional 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 information

BUSINESS, EXECUTIVE, LIFE COACHES PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

BUSINESS, 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 information

Find Me A Trainer Insurance Offer

Find Me A Trainer Insurance Offer Find Me A Trainer Insurance Offer Get Covered. Whether you are just starting out or have been in the industry for years, you will need Public Liability and Professional Indemnity insurance that protects

More information

BUSINESS LIABILITY APPLICATION

BUSINESS 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 information

ACCOUNTANTS, BOOKKEEPERS & RELATED PROFESSIONS PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

ACCOUNTANTS, 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 information

Couriers insurance package form

Couriers insurance package form Page 1 of 5 Couriers insurance package form Important Information Duty of Disclosure Before you enter into a contract of insurance, you have a duty under the Insurance Contracts Act 1984 (Cth) to disclose

More information

Professional Indemnity Proposal Form. for. Finance & Mortgage Brokers

Professional Indemnity Proposal Form. for. Finance & Mortgage Brokers Professional Indemnity Proposal Form for Finance & Mortgage Brokers Address: 5/3352 Pacific Highway Postal: PO Box 976 Springwood QLD 4127 Springwood QLD 4127 Phone: 07 3387 2800 Fax: 07 3208 2200 Email:

More information

Professional Indemnity Insurance AILA Proposal

Professional Indemnity Insurance AILA Proposal Professional Indemnity Insurance AILA Proposal September 2013 Please return this completed proposal to: Lynn Wainstein Lauren Malkin Tel (03) 9613 1442 Tel (03) 9613 1423 Email Lynn.Wainstein@jlta.com.au

More information

How To Get Insurance For A Car

How To Get Insurance For A Car Veterinarians Professional indemnity insurance (including optional public and products liability insurance and employment practices liability insurance) Proposal form 2011-2012 Please return completed

More information

MOTOR VEHICLE PROPOSAL FORM

MOTOR VEHICLE PROPOSAL FORM Commercial and Trucksure Pty Ltd As agent for the Insurer ABN: 78 078 661 220 AFSL: 238151 Level 6, 3 Spring Street Sydney NSW 2000 PO Box R1940 Royal Exchange NSW 1225 Telephone: (02) 9251 1155 Facsimile:

More information

CHILDCARE PROPERTY OWNERS INSURANCE APPLICATION FORM

CHILDCARE 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 information

Action Insurance Brokers Pty Ltd Public Liability Insurance Proposal

Action 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 information

Entertainment & Event Liability Insurance Proposal

Entertainment & 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 information

SHORT FILMS, TV COMMERCIALS, DOCUMENTARIES AND MUSIC VIDEOS PROPOSAL FORM

SHORT FILMS, TV COMMERCIALS, DOCUMENTARIES AND MUSIC VIDEOS PROPOSAL FORM SURA FILM AND ENTERTAINMENT PTY LTD LEVEL 13 / 141 WALKER ST NORTH SYDNEY NSW 2060 PO BOX 1813 NORTH SYDNEY NSW 2059 SHORT FILMS, TV COMMERCIALS, DOCUMENTARIES AND MUSIC VIDEOS PROPOSAL FORM 09-15 SHORT

More information

Professional Trainers, Licensing Assessment and Consultancy Services Professional Indemnity and Public Liability Insurance Proposal Form

Professional 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 information

Will you be claiming any Input Tax Credits on the GST applicable to this policy? Yes No If Yes, what percentage? % Suburb State Postcode

Will you be claiming any Input Tax Credits on the GST applicable to this policy? Yes No If Yes, what percentage? % Suburb State Postcode Accountants Professional Indemnity Insurance. Proposal Form Please complete and return this proposal form to Aon Risk Services Australia Ltd, GPO Box 1230, Melbourne VIC 3001 If you have any questions,

More information

HOME INDEMNITY INSURANCE - WESTERN AUSTRALIA POLICY WORDING

HOME INDEMNITY INSURANCE - WESTERN AUSTRALIA POLICY WORDING POLICY WORDING HOME INDEMNITY INSURANCE - WESTERN AUSTRALIA GLA RBUA HII WA 1115 Effective Date 01 November 2015 Welcome to the financial security provided by RBUA Home Indemnity Insurance - Western Australia

More information

AUCTIONEERS & VALUERS ASSOCIATION OF AUSTRALIA

AUCTIONEERS & VALUERS ASSOCIATION OF AUSTRALIA Professional Indemnity Insurance Proposal Form AUCTIONEERS & VALUERS ASSOCIATION OF AUSTRALIA IMPORTANT NOTICE Your Duty of Disclosure Before you enter into a contact of general insurance with any insurer,

More information

Professional Indemnity Proposal form

Professional 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 information

IMPORTANT NOTICE PLEASE READ THE FOLLOWING ADVICE BEFORE PROCEEDING TO COMPLETE THIS PROPOSAL FORM

IMPORTANT NOTICE PLEASE READ THE FOLLOWING ADVICE BEFORE PROCEEDING TO COMPLETE THIS PROPOSAL FORM IMPORTANT NOTICE PLEASE READ THE FOLLOWING ADVICE BEFORE PROCEEDING TO COMPLETE THIS PROPOSAL FORM Your Professional Indemnity Insurance Policy is issued on a CLAIMS MADE basis. This means that this policy

More information

Contractual Liability

Contractual Liability Contractual Liability Claim Form IMPORTANT NOTES FOR YOUR INFORMATION 1 Ensure you: a. observe the principles of Utmost Good Faith, b. comply with your Duty of Disclosure, c. comply with the General Condition

More information

CONSTRUCTION INSURANCE OWNER BUILDER APPLICATION

CONSTRUCTION INSURANCE OWNER BUILDER APPLICATION SURA CONSTRUCTION PTY LTD LEVEL 13 / 141 WALKER ST NORTH SYDNEY NSW 2060 P O BOX 1813 NORTH SYDNEY NSW 2059 CONSTRUCTION INSURANCE OWNER BUILDER APPLICATION CONSTRUCTION INSURANCE OWNER BUILDER APPLICATION

More information

Sports Injury Claim Form

Sports Injury Claim Form Sports Underwriting Australia Sports Underwriting Australia Claims Department PO E: liabilityclaims@sportsunderwriting.com.au Box 2717, Taren Point. NSW, 2229 Tel: Ph: 1300 363 363 413 413 Fax: +61 2 9524

More information

DAWES MOTOR INSURANCE MOTORCYCLE CLAIM FORM IMPORTANT NOTICES

DAWES MOTOR INSURANCE MOTORCYCLE CLAIM FORM IMPORTANT NOTICES DAWES MOTOR INSURANCE MOTORCYCLE CLAIM FORM P.O. Box 2717 Taren Point NSW 2229 Phone: 1300 188 299 Fax: 1300 662 215 claims@dawes.com.au To ensure prompt attention to your claim, please complete this form

More information

labour force professional liability insurance

labour 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 information

Professional Indemnity Insurance Proposal Form for Actuaries (short form)

Professional Indemnity Insurance Proposal Form for Actuaries (short form) Professional Indemnity Insurance Proposal Form for Actuaries (short form) Marsh Pty Ltd ABN 86 004 651 512 Darling Park Tower 3 201 Sussex Street SYDNEY NSW 2000 PO Box H176 AUSTRALIA SQUARE NSW 1215 Telephone

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL NOTICE TO INSURED (Pursuant to the provisions of the Insurance Contracts Act 1984) Your Duty of Disclosure Before you enter into a contract of general insurance with an insurer, you have a duty, under

More information

Professional Indemnity Proposal Form. for. Financial Planners

Professional Indemnity Proposal Form. for. Financial Planners Professional Indemnity Proposal Form for Financial Planners Address: 5/3352 Pacific Highway Postal: PO Box 976 Springwood QLD 4127 Springwood QLD 4127 Phone: 07 3387 2800 Fax: 07 3208 2200 Email: pidirect@pidirect.com.au

More information

PROPOSAL 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. 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 information

Breeze Underwriting Application Form Accountants Professional Indemnity Insurance

Breeze Underwriting Application Form Accountants Professional Indemnity Insurance Application Form Accountants Professional Indemnity Insurance Send quotation requests to: Email: distribution@breezeuw.com.au Phone: 1300 556 826 IMPORTANT NOTICES Please read these Important tices before

More information

Coversure Security Industry Insurance Proposal

Coversure Security Industry 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) Postal Address Location of Premises

More information

Transportation Insurance

Transportation 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 information

ARCHITECTS, ENGINEERS, SURVEYORS & CONSTRUCTION INDUSTRIES PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

ARCHITECTS, 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 information

Liability Insurance Proposal

Liability Insurance Proposal Liability Insurance Proposal For Information Technology Entities Woodina Underwriting Agency Pty Ltd AFS Licence No. 418755 NOTICE TO INSURED (Pursuant to the provisions of the Insurance Contracts Act

More information

Professional Indemnity Insurance BDA Proposal

Professional Indemnity Insurance BDA Proposal Professional Indemnity Insurance BDA Proposal September 2012 Please return this completed proposal to: Kathleen Sutherland Unit 10, Building I1, 22 Powers Road Seven Hills NSW 2147 Tel 02 8824 1600 Fax

More information

REAL ESTATE AGENT / PROPERTY MANAGERS/ VALUER PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

REAL ESTATE AGENT / PROPERTY MANAGERS/ VALUER PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM REAL ESTATE AGENT / PROPERTY MANAGERS/ VALUER 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 information

Professional Indemnity Insurance Application Form Marsh Accountants Insurance Program

Professional Indemnity Insurance Application Form Marsh Accountants Insurance Program Professional Indemnity Insurance Application Form Marsh Accountants Insurance Program Phone: 1300 093 634 Email: accountants@marsh.com tice to the Applicant This notice must be read before you complete

More information

Suburb State Postcode Residential address. Suburb State Postcode

Suburb State Postcode Residential address. Suburb State Postcode Classic and Collector Vehicle & Motorcycle Insurance quotation & proposal form Broker or dealer details Company Name Phone Email Page 1 of 7 The applicant Full name Date of birth Email Postal address Phone

More information

Professional Indemnity Insurance Application

Professional Indemnity Insurance Application Professional Indemnity Insurance Application Office Use Only Core Customer Segment Account Number Policy Number Important Notices Duty of Disclosure Before you enter into a contract of insurance with Ansvar

More information

PROFESSIONAL INDEMNITY GENERAL LIABILITY AND MANAGEMENT LIABILITY INSURANCE COMBINED PROPOSAL (RECRUITMENT SERVICES)

PROFESSIONAL INDEMNITY GENERAL LIABILITY AND MANAGEMENT LIABILITY INSURANCE COMBINED PROPOSAL (RECRUITMENT SERVICES) PROFESSIONAL INDEMNITY GENERAL LIABILITY AND MANAGEMENT LIABILITY INSURANCE COMBINED PROPOSAL (RECRUITMENT SERVICES) IMPORTANT NOTICES: CLAIMS MADE POLICY: This Proposal is for a policy issued by ProRisk

More information

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM

PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM PROFESSIONAL INDEMNITY INSURANCE PROPOSAL FORM IMPORTANT TICES - `CLAIMS MADE CONTRACTS OF INSURANCE Please read the following carefully before completing this proposal form: Your professional indemnity

More information

Public Relations / Marketing Consultants. Professional Indemnity Insurance

Public Relations / Marketing Consultants. Professional Indemnity Insurance Public Relations / Marketing Consultants Public Relations Consultants Marketing Consultants Market Research Consultants Advertising Consultants Graphic Designers Professional Indemnity Insurance Proposal

More information

Professional Trainers, Licensing Assessment and Consultancy Services Professional Indemnity and Public Liability Insurance Proposal Form

Professional 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 information

QBE FORWARD Cover BROADFORM PUBLIC & PRODUCTS LIABILITY INSURANCE

QBE 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 information

labour force professional liability insurance

labour 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 information