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1300 669 664
Cleaning Contractors
1
Business Information
2
Operational Information
3
Industry specific
4
History
5
Personal details.
6
Duty of Disclosure
If you need help, please call our office during business hours and we will get one of our staff to complete this over the phone for you or help you with any queries you may have.
First Name
*
Last Name
*
Company name
*
Trading name
ABN
*
Years of Experience in industry
*
Operational Information
Business Occupation
*
Detailed Description of Work
*
Date business commenced operations
*
Has there been any major change in the business activities over recent years or is any anticipated in the near future?
*
Yes
No
If "yes" please give details
Estimated Annual Turnover This year
*
Turnover last year
Number of Full Time Staff:
*
Number of Part Time Staff:
Estimated Payments to Contractors ($0 if Nil)
*
Estimated Payments for Labour hire ($0 if Nil)
*
If contractors and sub-contractors, labour hire are engaged, advise nature of work undertaken:
Liability Limit Required
*
$5 Million
$10 Million
$20 Million
Turnover % derived from:
After Hours Cleaning %
Shopping Centre, Supermarket or Common Area Cleaning During Hours %
Other Cleaning or Activities %
Other Cleaning or Activities Please Specify Detail
Does the Insured Perform Spot Cleaning During Operational Hours?
*
Yes
No
Does the Insured Operate a Manual or Electronic Register of Inspection or Attendance Times?
*
Manual
Electronic
What Plant or Equipment is Used by the Insured?*
*
Provide Details of Cleaning Preparations of Chemicals Used by the Insured*:
Does the Insured Mix or Blend Chemicals etc. Other Than as Set Down in Manufacturer’s Specifications?
*
Yes
No
Details if "yes"
Do you undertake any work on refineries; chemical plant; petrol, oil or gas production facilities, offshore platforms/oil rigs; utilities, oil, or gas pipelines, power stations, silo's; cool rooms; laboratories; water treatment plants; railways or railway infrastructure; airports; underground work; bridges; dams; any work on conveyor belt systems; work on trains, watercraft or aircraft, atmosphere controlled sites (Computer Rooms, or the like)?
*
Yes
No
Have your or any partner or director:
Been declared bankrupt or had legal proceeding lodged against you?
*
Yes
No
Had an insurer that has declined to insure you?
*
Yes
No
Had an insurer that has declined to renew your insurance?
*
Yes
No
Had an insurer that has imposed special conditions on your insurance?
*
Yes
No
Have you within the last 10 years, suffered a claim that would have been covered by this insurance and or claimed for any loss or damage or received any demand or writ for personal injury or damage to property?
*
Yes
No
After enquiry, are you or any director or employee aware of or have any grounds for suspecting any circumstances which might give rise to a claim, against you or against any of the present or former directors during the last 10 years?
*
Yes
No
Please provide full details, if any answers to the above questions are Yes. With any previous claims, please detail amount paid or reserved, the year and your excess at the time and background information on the claim.
Phone Number
*
Email
*
Street Address
*
City / Suburb
*
State
*
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Postcode
*
Additional Comments
Upload A File
Accepted file types: pdf, jpg, png, doc, docx, xls, xlsx, Max. file size: 16 MB.
Duty of Disclosure
You must comply with your Duty of Disclosure when you apply for insurance with us and each time you renew or alter your cover. You have a duty of disclosure to tell us everything you know or should know, that is relevant to our decision to insure anyone under the policy, including you, and on what terms. It includes matters we specifically ask about when you apply for a policy, or renew or alter your policy, and any other matters which might affect whether we insure you and on what terms. The information you tell us can affect:
The amount of your premium and your excess, if we will insure you, if special conditions will apply to your policy.
You do not need to tell us of anything which:
Reduces the chances of you making a claim, we should know about because of the business we are in or we tell you we do not want to know
If you are unsure it is better to tell us. If you do not tell us something which you know or should know is relevant, the insurer might reduce a claim, refuse to pay a claim, cancel your policy or, if fraud is involved they can treat the policy as if it had never existed.
The duty of disclosure applies to every person or organisation insured under the policy. If you fail to comply with your duty of disclosure the insurer may be entitled to reduce their liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, they may also have the option of avoiding the contract from its beginning.
Do you understand and accept your duty of disclosure?
*
Yes I accept and understand my Duty of Disclosure
Commercial cleaners please use the form found
here
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