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Dog Industry Insurance
Your details
*Required
Your business name:
*
List all entities to be insured.
Your name:
*
First
Last
Phone Number
*
Email
*
Address
*
Suburb
*
State
*
Postcode
*
Country
*
Insurance and limitis
Do you currently have insurance?
*
Yes
No
Provide your current insurance company?
*
Type of insurance required:
*
Public Liability
Professional Indemnity
Date insurance is required from:
*
Limit of indemnity required, Public Liability:
*
Please select one
$10,000,000
$20,000,000
Limit of indemnity required, Professional indemnity:
*
Please select one
$1,000,000
$2,000,000
Do you require information on Income Protection Insurance / Personal Accident Insurance?
*
Yes
No
Do you require information on Motor Vehicle Insurance?
*
Yes
No
Do you require information on General Property Insurance (tools of trade, laptops, training equipment etc)?
*
Yes
No
Do you require information on any other class of insurance? e.g Property Insurance – Fire & Theft, Money, Tax Audit etc.
*
Yes
No
Business information
Are you a member of ANZCA?
*
Yes
No
Do you have a Certificate 3 or greater in Dog Training?
*
Yes
No
What is your Estimated Annual Turnover (Gross Takings before Expenses) for the following 12 months:
*
$
Please provide the approximate percentage of your activities (based on fee income/turnover) applicable to each state or territory (total must equal 100%):
NSW %
*
ACT %
*
OLD %
*
VIC %
*
TAS %
*
SA %
*
WA %
*
NT %
*
Number of employees:
*
Please provide a detailed description of all your business activities:
*
Do your business activities include:
Breeding (including artificial insemination) or sale of dogs?
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Yes
No
If yes, please provide details:
*
Board and train, including in-home boarding and use of third party boarding facilities
*
Yes
No
If yes, please provide details:
*
Training and/or kennelling for sporting animals (i.e. greyhounds)
*
Yes
No
If yes, please provide details:
*
Is your business involved in any event organising including demonstrations or shows?
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Yes
No
If yes, please provide further information:
*
Operate outside of Australia:
*
Yes
No
If yes, please provide details:
*
Do you engage Consultants, Contractors, Sub-Contractors?
*
Yes
No
If Yes, provide the estimated annual total payments made
*
Please provide the date your business was established?
*
If the answer to any of the following questions is yes, please provide details.
Do you assume liability under any contractual agreements?
*
Yes
No
(i.e have you agreed to accept another person’s potential liability)
If yes, please provide details:
*
Have you entered into any Contract or Agreement whereby you “Hold harmless” or have waived the Insurers right of recovery from any person or company following a claim being made against you?
*
Yes
No
If yes, please provide details:
*
Have you been charged with or convicted of any criminal offence in the past 5 years?
*
Yes
No
If yes, please provide details:
*
Have you or any partner(s), directors(s) or shareholder(s) ever been declared bankrupt?
*
Yes
No
If yes, please provide details:
*
Has any Partner, Principal, Director, or staff member ever been subject to disciplinary proceedings for professional misconduct?
*
Yes
No
If yes, please provide details:
*
Have any claims for negligence or breach of professional duty been made in the last ten (10) years againist the Practice or any of their predecessors in business or any prior practice of any of their present of former Partners, Prinicipals or Directors, or have circumstances been notified that might give rise to a claim?
*
Yes
No
If yes, please provide details:
*
Any of the Partners, Principals or Directors, AFTER ENQUIRY, aware of any claim or circumstance that might give rise to claim against the Practice or any prior practice of any of their present or former Partners, Principals or Directors wich matter is not referred to in the above question?
*
Yes
No
If yes, please provide details:
*
Has the Practice or any Partner, Prinicipal or Director ever been refused this type of insurance, or had similar insurance cancelled, or had an application of renewal declined, or had special terms imposed?
*
Yes
No
If yes, please provide details:
*
DECLARATION AND AUTHORITY
This declaration must be completed and signed by or on behalf of the party applying for insurance. I/We
a) declare that:
I am athorised to complete and sign this insurance application on behalf of the practice.
The responses provided are made based on information provided to me by the Principals, Partners and officers of the Practice.
I authorsie QBE Insurance (Australia) Limited ABN 78 003 191 035 to give or obtain from other insurers or insurance reference bureaus or credit card reporting agencies, any information about this insurance or any other insurance held by the Practice including this completed application and the Practice's claims history and credit history.
I/we have read and understood the
Financial Services Guide
and
Privacy Statement
;
Do you agree to the above declaration?
*
Please select
Yes
No
Upload additional information or a copy of your current insurance here:
*
Max file size: 20MB
Please send all correspondence by email:
*
- Please select -
Yes
No, send by regular post
Signature:
*
Date:
*
How did you hear about us?
*
Word of mouth
Internet/Google
Advertising
We contacted you
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