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Public Liability Form
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Indicates required field
General Information
Legal Entity:
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Trading Name(s):
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ABN:
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Phone Number
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Name
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First
Last
Email
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Website:
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Period of Insurance - From:
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Date format: 01/01/0000
Period of Insurance - To:
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Format: 00/00/0000
Business Information
Please describe business activities and/or occupation:
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Please advise the following
Turnover $AUD (last financial year):
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Number of employees (inc directors & partners):
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Date business commenced:
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Date format: 01/01/0000
Turnover $AUD (estimated next financial year):
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Turnover Split per state/territory (%)
ACT:
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%
NSW:
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%
VIC:
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%
QLD:
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%
SA:
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%
WA:
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%
TAS:
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%
NT:
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%
Limits of Liability:
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5,000,000
10,000,000
20,000,000
Other
Risk
Do you manufacture products?:
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Yes
No
If yes please complete import/export questions
Exports
Do you export any of your products?
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Yes
No
Country Exported to:
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Product / Component:
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Turnover Derived from Exports:
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Do you transport, handle, store or use hazardous goods or products? :
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Yes
No
If yes please provide details:
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Does your business create trade waste?:
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Yes
No
If yes please provide details:
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Do you employ sub-contractors?
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Yes
No
If yes please provide activities and estimated annual payments below:
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Do you obtain a certificate of insurance from sub-contractors? :
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Yes
No
Do you ask sub-contractors to name you as a principal on their liability policy?:
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Yes
No
If no how do you identify they have adequate insurance:
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General History
After investigation are you or any principal, director or partner aware of:
Any insurance claims declined or cancel, proposals rejected, refusal of renewal, claims rejected or special conditions imposed?:
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Yes
No
Any claims made against you?:
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Yes
No
Any incident or accident which would be insured by this proposed insurance?:
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Yes
No
Anyone having been convicted of a criminal offence (excluding traffic offences)? :
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Yes
No
Have any products ever been recalled?:
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Yes
No
Have you ever, either alone or jointly been declared bankrupt or subject to any form of insolvency administration?:
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Yes
No
If yes please provide details:
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Declaration
iv. I/we have read and understood the
Financial Services Guide
and
Privacy Statement
;
This declaration must be completed and signed by or on behalf of the party applying for insurance. I/We
a) declare that:
i. the answers and information given by me/us in this Application are true and correct in all respects;
ii. no information has been withheld that would affect an insurer's decision to accept this Application;
iii. where answers in this online application have not been completed by myself, they have been checked by me/us and I/we agree they are correct and true;
iv. I/we have read and understood the
Financial Services Guide
and
Privacy Statement
;
v. if there was insufficient space to fully answer any questions, I/we have attached supplementary pages providing the additional information required.
b) authorise National Insurance Group to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to these insurance covers, and any other insurances held by me/us and claims under those insurances.
Upload additional information or a copy of your current insurance here:
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Max file size: 20MB
Please send all correspondence by email:
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- Please select -
Yes
No, send by regular post
Signature
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Today's date:
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How did you hear about us?
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Word of mouth
Internet/Google
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We contacted you
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