Contact name
*
Phone
*
(###)
###
####
Email
*
Business name
*
Business address
*
Current insurer
Please select
360
Allianz
ATC
BizCover
CGU
Chase
Mecon
Other
No previous insurance
Preferred start date
MM
DD
YYYY
Business occupation
*
Please select
Residential builder (new and/or alterations)
Commercial builder (new and/or alterations)
Residential & commercial builder
Civil contractor
Trade subcontractor
Other
Public & Products Liability
*
Please select
$10,000,000
$20,000,000
Other
Number of employees
Maximum construction period
*
Please select
12 months
18 months
24 months
Over 24 months
Unregistered plant tools & equipment
*
Please select
$0
$10,000
$15,000
$20,000
$30,000
$50,000+
Number of storeys
*
Please select
1-3
1-6
6-10
10+
Maximum excavation depth
*
Please select
0-3 metres
3-5 metres
5+ metres
Do you anticipate your projects will involve any of the following:
*
You have a duty of disclosure should any of your selections change following submission of this form, as well as throughout your policy period.
Please provide additional information for anything you have selected above:
Industrial %
Institutional %
Please provide detail of all projects currently under construction and not yet completed.
Your new insurer will agree to cover all current projects, providing they are disclosed.
Start date | Estimated completion date | Contract value ($) | Site address | Amount of work yet to be completed ($)
Has the Insured had any Contract Works or Third Party Liability claims in the past five years?
Please select
Yes
No
If yes, please provide details of:
Date of loss | Claim description | Claim amount
Have any insurers ever declined your proposal/application?
Have any insurers refused or cancelled cover or imposed special conditions in respect of the proposed insurance?
Have you or any person applying for this insurance ever been declared bankrupt, insolvent, had liquidators appointed, been a defendant in a civil court case, or convicted of any criminal offence?
If you have answered yes to any of the above, please provide full details:
