Main Contact – Name(s)

Email

Phone Number

Postal Address

Entity Name

ABN

Business Activities

If "overseas" is selected, please provide details of countries and income derived

Do you handle Dangerous Goods

Do you handle Asbestos?

Do you work at any of the following:

• Drag Line Excavators

• Highvoltage Power Supply Areas

• Airport Tarmacs and Aircraft Hangars

• Wharves and Ship Handling Facilities

• Underground Mines

• Railway Tracks and Related Infrastructure

• Steelworks

Do you Perform any Welding?

Do you work over 10m in height?

Do you dig more than 2m in depth?

Do you Import or Export?

Do you assume liability or contract in additional exposure?

Do all subcontractors carry their own Public & Products Liability insurance?

Number of Full Time Employees

Number of Part Time or Casual Employees

PUBLIC LIABILITY

PRODUCTS LIABILITY

Previous Claims Declined?
Please SelectYesNoLet's Discuss

Ever been liable for any civil offence or pecuniary penalty?
Please SelectYesNoLet's Discuss

Ever been charged or convicted of a criminal offence?
Please SelectYesNoLet's Discuss

Ever had an insurance policy cancelled, declined or terms imposed?
Please SelectYesNoLet's Discuss

Aware of circumstances which could give rise to a claim?
Please SelectYesNoLet's Discuss

Anything to Declare under Duty of Disclosure?
Please SelectYesNoLet's Discuss

let's SIMPLIFY MY INSURANCE