Renewal Declaration Form

Do you require your insurance renewed?*

As we have not been able to assess your insurance requirements over the phone, would you like for us to give you a call to discuss your individual requirements?*

Name*

Company or trading name*

ABN

Phone Number*

Estimated Turnover For The Next 12 Months*

Please note an increased turnover will generally increase the premium.

Do your sub-contractors have their own Public Liability Insurance*

Estimated Payments to Sub-Contractors For The Next 12 Months*

Number of employees (including yourself)*

Have your or do you expect your occupational activities to change from the occupation description noted in your current insurance schedule and/or have you changed your business name or structure with ASIC?*

Please explain the changes*

Do you import or export?*

Do you undertake any work on, or operate a business that is/has: Labour Hire, a refinery, chemical plant, petrol oil or gas production facilities or pipelines, offshore platforms, oil rigs, utilities, power station, silo's, water treatment plants, railways or railway infrastructure, airport, underground work, dams, above or below ground mine sites, trains, watercraft or any other marine or maritime exposure, aircraft, scaffolding, asbestos removal, pest control, nightclub, bar, pub, demolition, tree lopping, civil construction, cranes or work on lifts*

What of the above do you do?*

In the last 5 years have you had any criminal convictions, been bankrupt, do you have any unreported claims or incidences that you may claim against, had any insurance declined or variations imposed or anything else that may affect your insurance that we should disclose to the underwriters on your behalf?*

Yes
No

Do you require quotes or further information on these insurance products?*

Management Liability (OH&S, Fairwork, ATO, ACCC & ASIC Investigation and legal costs cover)
Home & Contents Insurance
Tools cover
Commercial Vehicle, Truck, Plant or Equipment
Life or Income Protection Insurance
Cyber Liability (Cover against hacking and being held to ransom by Cyber criminals)
Other (Please describe Below)
Additional Quotes Not Required

Amount of tools cover required*

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 Information