Personal DetailsClient Name(Required)Company NameEmail(Required) Phone Number(Required)Address(Required)Occupation(Required)Suburb(Required)PostCode(Required)From What Date do you need insurance from?(Required) MM slash DD slash YYYY Insurance CoverPublic and Product Liability Limit $5 000 000 $10 000 000 $20 000 000 more then $20 000 000 Annual Estimate Turnover(Required)Do you engage contractors/subcontractors? Yes No What % of turnover you pay your subcontractors?General Information and DisclosureSelect if you conduct work at or in connection with:(Required)SelectNone of the belowPower stationsNuclear installations or establishments;RefineriesOil gas or chemical industriesOffshore structures or work underground or underwaterAircraft hovercraft aerospace systems or watercraftRailways (trackside)Aerodromes or airportsMine sitesElevators Escalators TravelatorsTower Cranes or Derrick CranesAsbestos RemovalMedical/Hospital FacilitiesHigh voltage power linesOperate the business outside of AustraliaPublic UtilitiesBridges or damsUse of the explosivesHandle hazardous substancesShip or Marine RiskDo you engage in any of the following activities?(Required)SelectNone of the belowWorking on heights over 10 meterWork under 3 meters in depthCommercial workDriving RiskDesigned contracts and Hold Harmless agreementsPerform hot works away from premisesHire out equipment or staffSelect if you or any partner(s) or director(s) of the business have(Required) None of the below Insurance policy cancelled or declined Ever been declared bankrupt Been insolvent or in voluntary administration Been convicted of any criminal offence Been liable for any civil offence or pecuniary penalty Special Conditions Imposed on the policy Have you had any Insurance Claims in the last 5 Years? *(Required)Other Relevant Information you wish to disclose
