Public Liability Insurance Questionnaire "*" indicates required fields Step 1 of 7 14% General InformationClient Type*IndividualSole TraderBusinessABN If applicableCompany name If applicableTrading as If applicablePerson completing this form* First Last Capacity/ relationship*Owner of vehicle/businessEmployee of businessOtherContact email address* Contact number* Business address* Business InformationProjected gross turnover for the next twelve months?*Number of employees* What % of turnover is paid to Bona Fide subcontractors?*A Bona Fide subcontractor is a subcontractor who works independently, using their own tools and materials, to complete a specialist job as a part of a wider project. What percentage of turnover is paid to personnel from labour hire companies?* Are subcontractors required to carry their own insurances?* Yes No Do you always check the insurances of the subcontractors?* Yes No Is the insured's payroll more than $1,000,000?* Yes No How much industry experience does the insured have in years?* Areas where work is performedStates/turnover split. Total must add up to 100%ACT %* NSW %* NT %* SA %* VIC %* QLD%* WA %* Underwriting questionsHas the Insured entered into any contracts or agreements where they have assumed the liability of others or released others from liability (hold harmless)?* Yes No Has the insured or any director or partner involved with the Business or any other business have in the past 5 years ever been convicted, charged or cautioned in respect of any criminal offence other than a motoring offence?* Yes No Has the insured or any director or partner involved with the Business or any other business have in the past 5 years ever been convicted of any offence relating to the Health and Safety of their employees or members of the public in connection with their business?* Yes No Has the insured or any director or partner involved with the business or any other business experienced any claims or are aware of any circumstances including regulatory investigations that could give rise to a claim that may have been covered by this policy?* Yes No Has the insured or any director or partner involved with the Business or any other business have in the past 5 years ever been declared bankrupt or insolvent?* Yes No Has the insured or any director or partner involved with the Business or any other business have in the past 5 years ever had any previous insurer decline a proposal, refuse to renew a policy or impose special terms or conditions?* Yes No Will the insured hold the relevant qualifications/licences (if required) for undertaking all aspects of their work?* Yes No Does the Insured manufacture, supply, distribute or sell any products?* Yes No Does the insured do oil and gas offshore work?* Yes No Does the insured's work involve structural welding/fabrication?* Yes No Does the insured conduct work at or in connection with:Please check the box next to all statements that apply to your situation. Power stations, nuclear installations or establishments Refineries, bulk storage or production premises in the oil, gas or chemical industries Offshore structures or work underground or underwater Mainframe computers or dedicated computer sites Aircraft, hovercraft, aerospace systems or watercraft (other than work on watercraft in docks, harbours, boatyards or inland waterways not involving the use of heat) Railways (trackside) Aerodromes or airports Mine sites Elevators / Escalators / Travelators Tower Cranes or Derrick Cranes Water Treatment Plants Amusement Rides, Rollercoasters or Theme Park Attractions Does the insured's business use hazardous chemicals and / or Pharmaceutical manufacture?* Yes No Does the insured employ any staff that they will hire or subcontract out to others?* Yes No Do you undertake any work relating to tunnels, towers, bridges or dams?* Yes No Does the insured or any sub-contractors engaged by the insured undertake any Blasting Activities?* Yes No Does the insured undertake any Asbestos removal?* Yes No Does the insured work or operate the business outside of Australia?* Yes No Does the insured work on railways?* Yes No Does the insured work on power lines?* Yes No Is the insured engaged to perform vegetation maintenance (including the felling or lopping trees) of electricity corridors?* Yes No Does the insured work airside?* Yes No Duty of DisclosureYour duty of disclosure*Before you enter into an insurance contract, you have a duty of disclosure under the Insurance Contracts Act 1984. If we ask you questions that are relevant to our decision to insure you and on what terms, you must tell us anything that you know and that a reasonable person in the circumstances would include in answering the questions. You have this duty until we agree to insure you. If you do not tell us something If you do not tell us anything you are required to tell us, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both. If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed. I have read and I understand my duty of disclosure. CommentsThis field is for validation purposes and should be left unchanged.
