| 1. Name of companies proposed to be insured |
|
| Your ABN |
|
| Date first established |
|
| Insured is: |
An
Individual |
|
A Partnership |
|
A Corporation |
|
Other (please specify)
|
| 2. Principal Address |
|
| Email Address |
|
| Telephone |
|
| Fax |
|
| Mobile |
|
| 3. Period of Insurance |
From
to
|
| 4. Limit of indemnity required |
|
| A) PUBLIC LIABILITY |
$
any one occurence |
| B) PRODUCTS LIABILITY |
$
any one period of insurance |
| C) PROFESSIONAL INDEMNITY |
$
any one period of insurance |
| 5. Full description of Insured's activities |
|
| A) Do you contract for powerline clearing |
Yes - If yes,
please advise total contract value $
|
|
No |
| 6. Please give details of: |
|
| A) Number and type of unregistered vehicles |
A
|
| B) Lifts, escalators, cranes, hoists or other lifting
equipment |
B
|
| 7. Turnover: |
|
| Actual - Past 12 months |
|
| Estimate - Next 12 months |
|
| 8. Number of years in continuous business |
|
| A) number of employees |
|
| Est. total annual wages |
|
| B) Do you use subcontractors? |
Yes - If "Yes", est. annual
wages
|
|
No |
| C) If you have been in business less than 12 months please state
previous experience and qualifications |
|
| 9. PROFESSIONAL OR OTHER SERVICES |
|
| Do you carry on any, professional, technical, consultancy,
advisory or like services either for a fee or as an ancillary service to the
business of the Proposer? |
Yes - If "Yes", give
detalis of such services and to whom such services are offered
|
|
No |
| 10. Give any detail of any agreements you have made under which you
have: |
|
| A) Accepted liability under which would normally not be your
responsibility |
A |
| B) Given away your legal rights of recovery from the other
parties |
B |
| 11. Loss history |
|
A) Please provide details of all liability claims made against you
Please complete - (if yes)
with details below, or (if no) indicate with none
|
|
|
|
| B) Are you aware of any other incident which may result in claims
against you? |
Yes
No |
| If "YES", give details |
| 12. PREVIOUS INSURANCE HISTORY |
|
| A) Name of insurer |
|
| 1
Years on Risk From
to
|
| 2
Years on Risk From
to
|
| B) Has any insurer cancelled, declined or refused to renew this
form of coverage? |
Yes
No |
| If "YES", give details
|
|
|
