Public and Products Liability Proposal Form

When completing this form, we appreciate not everything is applicable. If this is the case on a section, please write NA. 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
Please describe the activities of the business with as much detail as reasonably possible. Please note that answers such as, Retail, Wholesale, electrical or other one word answers, used to describe your occupation will result in your request being deleted and no quote being offered. We need to submit this to companies that have no idea what your business does. Giving us a complete description of your duties, things worked on and occupational requirements help us to get you a more favourable quote:
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*
Liability Limit Required*
- $5 Million
- $10 Million
- $20 Million
- $20 Million +

Do you manufacture products*
- Yes
- No
1. Product Name, Description, use and turnover derived from the product.
2. Product Name, Description, use and turnover derived from the product.
If you have more than 2 products please either a) upload a list of the products or b) give us a link to your website where we can view your products.
a) Upload file
Max. file size: 10 MB.
or
Your website
Do you or do you intend to import or export any raw materials, components or finished goods?*
- Yes Import
- Yes Export
- Yes Import and Export
- I do not intend to import or export
If you answered "yes" please give the country and if you are importing or exporting from that country and the intended use of the product.

Phone Number*
Email*
Street Address*
City / Suburb*
State*
Postcode*
We offer finance broking as one of our services. Do you require pricing on any loans or finance?*
What type of finance do you require?*
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

Operational Information

If you have more than 2 products please either a) upload a list of the products or b) give us a link to your website where we can view your products.

or

Have your or any partner or director:

Duty of Disclosure

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.