Saturday, 19 May 2012
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Public Liability Insurance Proposal

  1. Period of Insurance

  2. From Date
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  3. To Date (4.00PM)
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  4. Insured Details

  5. Name of Insured (inc. all subsidiary companies)(*)
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  6. Postal Address(*)
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  7. Post Code(*)
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  8. Description of Business(*)
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  9. ABN
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  10. Business Phone(*)
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  11. Fax
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  12. Mobile
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  13. Email Address(*)
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  14.  

  1. Location of Premises

  2. Situation 1 : Address
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  3. State(*)
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  4. Post code(*)
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  5. Situation 2 : Address
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  6. State
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  7. Post Code
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  8.  

  1. Partners / Directors

  2. Partners/Director 1

  3. Name(*)
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  4. Years Experienced in Industry(*)
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  5. Years Experienced as Directors
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  6. Partners/Director 2

  7. Name
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  8. Years Experienced in Industry
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  9. Years Experienced as Directors
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  10. Partners/Director 3

  11. Name
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  12. Years Experienced in Industry
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  13. Years Experienced as Directors
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  14.  

  1. ** FIELDS MUST BE COMPLETED TO ENSURE PROMPT QUOTATION

  2. Years Business Established:(*)
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  3. **Number of security Staff: Full-time:(*)
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  4. ** Part-time:(*)
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  5. **Actual Turnover for last year: $(*)
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  6. ** Estimated Turnover for this year: $(*)
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  7. **Actual Wages for last year: $
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  8. ** Estimated Wages for this year: $
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  9. IF THIS SECTION IS NOT COMPLETED, CONSIDERATION WILL NOT BE GIVEN FOR DISCOUNT OF PREMIUM. **PLEASE ATTACH EVIDENCE OF THIS**

  10. Upload
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  11. **Do you use sub-contractors?(*)
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  12. Percentage of Activity Subcontracted (%)(*)
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  13. **If Yes, Actual Payments to sub-contractors for last year ($)(*)
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  14. **Estimated payments to Sub-contractors for this year ($)(*)
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  15. Do sub-contractors have their own insurance?(*)
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  16. If yes, note details of certificate of Insurance

  17. Name of Insurer:
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  18. Limit of Indemnity:
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  19. Policy No:
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  20.  

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

  2. Period Of Insurance

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

  6. Design or alteration of security systems (This Year / Last Year)
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  7. Installation of security systems
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  8. Investigation
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  9. Service & maintenance of security systems
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  10. Static guarding eg. Business premises, shopping
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  11. Centres, banks, gate-houses
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  12. Mobile patrols
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  13. Responding to alarms
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  14. Cash carry
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  15. Use of Firearms
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  16. Use of Dogs
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  17. Body guarding
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  18. Debt collections
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  19. Traffic control
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  20. Education programmes, i.e. self defence etc
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  21. Fire arms training
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  22. Guard dog training and/or breeding and/or sale of dogs
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  23. Monitoring of alarms
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  24. Manufacture of security systems
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  25. Crowd Control
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  26. - Hotels
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  27. - Concerts
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  28. - Discos
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  29. - Entertainment venues
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  30. Other
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  31. If other, please provide details:
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  32.  

  1. Cover

  2. Limit of Liability(*)
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  3. Extensions
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  4. Do You Require Errors & Omissions:
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  5. If so, for what activities:
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  6. Guard Dog Security

  7. Do you provide guard dog security?(*)
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  8. Total number of dogs?
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  9. Are dogs permanently under control of handler?
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  10. If no, please provide details:
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  11. Are all dogs properly kennelled when not being used for guard duty?
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  12. Are all dogs professionally trained prior to being used for guard duty?
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  13.  

  1. Firearms

  2. Do you use firearms?
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  3. If Yes, please state:

  4. What percentage of your turnover is derived from gun use? (%)
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  5. Number of guards licenced to use guns?
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  6. Number and type of firearms used?
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  7. Are firearms serviced each year?

  8. How often is shooting practice undertaken each year and provide details
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  9. Confirm all firearms are licenced and is copy of licence sighted?
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  10. Confirm all guns are stored, when not is use, under government approved storage conditions.
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  11.  

  1. Batons

  2. Do you use batons?(*)
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  3. If yes, please state:

  4. Number and type of batons used
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  5. Please provide details of training undertaken
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  6. Warning signs & Notices

  7. Do you provide warning signs or notices?(*)
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  8. If yes, please state:

  9. a) Type of signs/notices
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  10. b) Are signs well posted and open to full display?
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  11. c) Do you display signs at minimum distances?
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  12. Do you provide any indemnities, hold harmless conditions to any customers, suppliers or other parties?(*)
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  13. If Yes, please give details
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  14. If yes, please provide a copy of the contract:
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  15. Do you contract to any State, Federal Authorities or Airports?
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  16. If Yes, please give details
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  17.  

  1. Your Previous History

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

  3. Suffered any loss, destruction or damage for risks to be insured under the proposed policy?(*)
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  4. Had any Insurer decline any claims submitted?(*)
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  5. Had any Insurer decline any Proposals submitted?(*)
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  6. Had any Insurer cancel or refuse to renew a Policy?(*)
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  7. Had any Insurer require any increased premium or imposed special conditions?(*)
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  8. Ever been bankrupt?(*)
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  9. Been convicted of or charged with any civil or criminal offence?(*)
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  10. If you answered “Yes” to any of the above, please give details
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  11. Insurance Declaration and Claims History

  12. Insured’s previous insurer
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  13. Expiry Date
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  14. Detail all insurance claims made in the last five years together with any uninsured losses. Please include dates and amounts.

  15. Date of Loss
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  16. Type of Loss
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  17. Amount
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  18. Name of Insurer
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  19. Date of Loss
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  20. Type of Loss
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  21. Amount
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  22. Name of Insurer
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  23. Date of Loss
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  24. Type of Loss
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  25. Amount
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  26. Name of Insurer
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  27. Date of Loss
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  28. Type of Loss
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  29. Amount
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  30. Name of Insurer
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  31. Date of Loss
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  32. Type of Loss
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  33. Amount
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  34. Name of Insurer
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  35.  

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

  2. I acknowledge that:

    1. I have read and understood the Important Information set out in the Proposal and I/We are authorised to make this proposal.
    2. All information given on this Proposal and any attachment is true and correct
    3. 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.
    4. 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.
    5. 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.

  3. I/We agree with the above statement(*)
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  4. Anti-Spam
    Anti-Spam
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  5. Submit