Public Liability Insurance Proposal Form - Action Insurance Brokers

Click here to download a hardcopy of this proposal

Period of Insurance

From Date

Invalid Input

To Date (4.00PM)

Invalid Input

Insured Details

Name of Insured (inc. all subsidiary companies)(*)

Invalid Input

Postal Address(*)

Invalid Input

Post Code(*)

Invalid Input

Description of Business(*)

Invalid Input

ABN

Invalid Input

Business Phone(*)

Invalid Input

Fax

Invalid Input

Mobile

Invalid Input

Email Address(*)

Invalid Input

Location of Premises

Situation 1 : Address

Invalid Input

State(*)

Invalid Input

Post code(*)

Invalid Input

Situation 2 : Address

Invalid Input

State

Invalid Input

Post Code

Invalid Input

Partners / Directors

Partners/Director 1

Name(*)

Invalid Input

Years Experienced in Industry(*)

Invalid Input

Years Experienced as Directors

Invalid Input

Partners/Director 2

Name

Invalid Input

Years Experienced in Industry

Invalid Input

Years Experienced as Directors

Invalid Input

Partners/Director 3

Name

Invalid Input

Years Experienced in Industry

Invalid Input

Years Experienced as Directors

Invalid Input

** FIELDS MUST BE COMPLETED TO ENSURE PROMPT QUOTATION

Years Business Established:(*)

Invalid Input

**Number of security Staff: Full-time:(*)

Invalid Input

** Part-time:(*)

Invalid Input

**Actual Turnover for last year: $(*)

Invalid Input

** Estimated Turnover for this year: $(*)

Invalid Input

**Actual Wages for last year: $

Invalid Input

** Estimated Wages for this year: $

Invalid Input

IF THIS SECTION IS NOT COMPLETED, CONSIDERATION WILL NOT BE GIVEN FOR DISCOUNT OF PREMIUM.

**PLEASE ATTACH EVIDENCE OF THIS**

Upload

Invalid Input

**Do you use sub-contractors?(*)

Invalid Input

Percentage of Activity Subcontracted (%)(*)

Invalid Input

**If Yes, Actual Payments to sub-contractors for last year ($)(*)

Invalid Input

**Estimated payments to Sub-contractors for this year ($)(*)

Invalid Input

Do sub-contractors have their own insurance?(*)

Invalid Input

If yes, note details of certificate of Insurance

Name of Insurer:

Invalid Input

Limit of Indemnity:

Invalid Input

Policy No:

Invalid Input

What percentage of turnover was/is derived from the following?

Period Of Insurance

Last Year

Invalid Input

This Year

Invalid Input

Please state turnover in percentages (This Year vs. Last Year) e.g. 20/30

Design or alteration of security systems (This Year / Last Year)

Invalid Input

Installation of security systems

Invalid Input

Investigation

Invalid Input

Service & maintenance of security systems

Invalid Input

Static guarding eg. Business premises, shopping

Invalid Input

Centres, banks, gate-houses

Invalid Input

Mobile patrols

Invalid Input

Responding to alarms

Invalid Input

Cash carry

Invalid Input

Use of Firearms

Invalid Input

Use of Dogs

Invalid Input

Body guarding

Invalid Input

Debt collections

Invalid Input

Traffic control

Invalid Input

Education programmes, i.e. self defence etc

Invalid Input

Fire arms training

Invalid Input

Guard dog training and/or breeding and/or sale of dogs

Invalid Input

Monitoring of alarms

Invalid Input

Manufacture of security systems

Invalid Input

Crowd Control

Invalid Input

- Hotels

Invalid Input

- Concerts

Invalid Input

- Discos

Invalid Input

- Entertainment venues

Invalid Input

Other

Invalid Input

If other, please provide details:

Invalid Input

Cover

Limit of Liability(*)

Invalid Input

Extensions

Tenants Liability

Products Liability

Property Owners Liability

Invalid Input

Do You Require Errors & Omissions:

Invalid Input

If so, for what activities:

Invalid Input

Guard Dog Security

Do you provide guard dog security?(*)

Invalid Input

Total number of dogs?

Invalid Input

Are dogs permanently under control of handler?

Invalid Input

If no, please provide details:

Invalid Input

Are all dogs properly kennelled when not being used for guard duty?

Invalid Input

Are all dogs professionally trained prior to being used for guard duty?

Invalid Input

Firearms

Do you use firearms?

Invalid Input

If Yes, please state:

What percentage of your turnover is derived from gun use? (%)

Invalid Input

Number of guards licenced to use guns?

Invalid Input

Number and type of firearms used?

Invalid Input

Are firearms serviced each year?

How often is shooting practice undertaken each year and provide details

Invalid Input

Confirm all firearms are licenced and is copy of licence sighted?

Invalid Input

Confirm all guns are stored, when not is use, under government approved storage conditions.

Invalid Input

Batons

Do you use batons?(*)

Invalid Input

If yes, please state:

Number and type of batons used

Invalid Input

Please provide details of training undertaken

Invalid Input

Warning signs & Notices

Do you provide warning signs or notices?(*)

Invalid Input

If yes, please state:

a) Type of signs/notices

Invalid Input

b) Are signs well posted and open to full display?

Invalid Input

c) Do you display signs at minimum distances?

Invalid Input

Do you provide any indemnities, hold harmless conditions to any customers, suppliers or other parties?(*)

Invalid Input

If Yes, please give details

Invalid Input

If yes, please provide a copy of the contract:

Invalid Input

Do you contract to any State, Federal Authorities or Airports?

Invalid Input

If Yes, please give details

Invalid Input

YOUR PREVIOUS HISTORY

Have you in the past, either alone or in partnership or jointly with any party, or if a corporation any of its directors:

Suffered any loss, destruction or damage for risks to be insured under the proposed policy?(*)

Invalid Input

Had any Insurer decline any claims submitted?(*)

Invalid Input

Had any Insurer decline any Proposals submitted?(*)

Invalid Input

Had any Insurer cancel or refuse to renew a Policy?(*)

Invalid Input

Had any Insurer require any increased premium or imposed special conditions?(*)

Invalid Input

Ever been bankrupt?(*)

Invalid Input

Been convicted of or charged with any civil or criminal offence?(*)

Invalid Input

If you answered “Yes” to any of the above, please give details

Invalid Input

Insurance Declaration and Claims History

Insured’s previous insurer

Invalid Input

Expiry Date

Invalid Input

Detail all insurance claims made in the last five years together with any uninsured losses. Please include dates and amounts.

Date of Loss

Invalid Input

Type of Loss

Invalid Input

Amount

Invalid Input

Name of Insurer

Invalid Input

Date of Loss

Invalid Input

Type of Loss

Invalid Input

Amount

Invalid Input

Name of Insurer

Invalid Input

Date of Loss

Invalid Input

Type of Loss

Invalid Input

Amount

Invalid Input

Name of Insurer

Invalid Input

Date of Loss

Invalid Input

Type of Loss

Invalid Input

Amount

Invalid Input

Name of Insurer

Invalid Input

Date of Loss

Invalid Input

Type of Loss

Invalid Input

Amount

Invalid Input

Name of Insurer

Invalid Input

Click here to please read the important information on Duty of Disclosure and Privacy

I acknowledge that:

I have read and understood the Important Information set out in the Proposal and I/We are authorised to make this proposal.

All information given on this Proposal and any attachment is true and correct

No insurance is in force until this Proposal has been accepted by the Insurer and the premium paid or unless an interim contract had been issued.

Up until a contract of insurance is entered into, I/We are under a continuing obligation to immediately inform Action Insurance Brokers P/L of any change in the particulars or statements contained in this proposal or in any attachments.

Although the signing of this proposal does not bind the applicants to effect insurance, the applicants acknowledge that the particulars and statements contained in this proposal and in the attachments shall be the basis of the contract should a policy be issued and the Applicants acknowledge that the Proposal and attachments will be incorporated in the Policy.

In submitting this form, I acknowledge that I may receive documentation from Action Insurance Brokers P/L by email. I further agree that Action Insurance Brokers P/L may from time to time send me important information about new insurance products and services.

I/We agree with the above statement(*)

Yes

No

Invalid Input

Anti-Spam(*)

Invalid Input

Submit

Public Liability Insurance Proposal

Company Information

Insurance Products

Services

Contact Us