Saturday, 19 May 2012
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Perform-Sure Proposal Form

  1. **PLEASE CLICK HERE TO READ IMPORTANT INFORMATION ON THE PERFORM-SURE PROPOSAL

    (Note: this will open up a new tab in your browser)

  2. Name of Performing Group(*)
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  3. ABN
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  4. Contact Person(*)
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  5. Postal Address(*)
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  6. Suburb(*)
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  7. State(*)
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  8. Postcode(*)
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  9. Phone Number(*)
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  10. Fax Number
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  11. Email Address(*)
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  12.  
  1. Please describe your activities in as much detail(*)
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  2. How many performers in your group? (Please note injuries to PAYG employees are excluded under this insurance).(*)
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  3. Period that cover is required for:
  4. From
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  5. To: 15th July (select year)
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  6. Cover
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  7. Estimated annual income (turnover): $(*)
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  8. Do you use contractors / sub-contractors?
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  9. Do you intend to hire out a performance venue to self-promote or stage your own performance?
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  10. Will you be signing any contracts that contain hold harmless or indemnity agreements?
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  11. Have you suffered any public liability claims or have caused incidents that could give rise to a public liability claim?
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  12. If yes, please provide details
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  13. Have you ever been convicted of a criminal offence?
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  14. Will your performances activities include:
  15. Audience participation with use of fire, sporting, hazardous or dangerous activities ?
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  16. Fireworks or pyrotechnics?
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  17. Use of animals?
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  18. Use of fire?
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  19. Use of amusement rides or devices?
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  20. Running of workshops?
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  21. Any activities conducted outside of Australia/New Zealand?
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  22. Additional Information
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  23. I/We hereby declare that the information provided by me/we in this proposal form is true and correct and that I/we have read and understand the Important Notices at the start of this questionnaire.

    I/We also agree that this questionnaire can be used as the proposal of insurance and therefore the basis of the contract of insurance between me/we and the underwriter, if so approved by the underwriter. 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.

  24. Do you agree?(*)
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  25. You can navigate back to previous pages of the form to check you have entered all correct details. Once you are satisfied, enter the security code below and then click on the SUBMIT button.
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