Contact name
*
Phone
*
(###)
###
####
Email
*
Business name
*
Business address
*
Preferred start date
MM
DD
YYYY
Business occupation
*
Public & Products Liability
*
Please select
$10,000,000
$20,000,000
Other
Number of employees
Unregistered plant tools & equipment
*
Please select
$0
$10,000
$15,000
$20,000
$30,000
$50,000+
Maximum height worked to
*
Please select
0-10 metres
10+ metres
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:
Has the Insured had any Public 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:
