Saturday, 19 May 2012
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Voluntary & Group Accident Insurance Questionnaire
  1. Please click here to read important information on the Voluntary and Group Accident Insurance proposal
  2. Where did you hear about Action Entertainment Insurance?
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  3. Contact Name
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  4. Insured name(*)
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  5. ABN #
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  6. Postal Address(*)
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  7. Suburb(*)
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  8. State(*)
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  9. Post Code(*)
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  10. Phone number(*)
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  11. Fax number
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  12. Email address(*)
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  13.  

  1. Period that cover is required for:

  2. From Date:
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  3. To Date (4.00PM):
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  4. Your Business Description(*)
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  5. How many voluntary workers or persons will you be engaging to work for you?(*)
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  6. Please advise age ranges (approx) of these persons:

  7. Youngest(*)
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  8. Oldest(*)
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  9. What activities or duties will these persons be conducting?(*)
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  10. How often will the Insured persons conduct Voluntary Work?(*)
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  11. Will these persons be engaged in any of the following:

  12. Lifting heavy equipment
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  13. Working from heights
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  14. If yes, please advise max height
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  15. Sporting activities
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  16. If yes, what type of sport
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  17. Acrobatic, aerial or trapeze
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  18. Dangerous or hazardous work
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  19. If yes, please describe
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  20. Driving vehicles
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  21. Will you be paying these persons to work for you?
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  22. If yes, please be aware that you might be required to arrange a workers compensation policy to cover these persons. Workers Compensation Insurance is compulsory for all employers. Please contact Action Insurance Brokers if you require further information on Workers Compensation Insurance.

  23. Have you suffered any claims or incidents where persons working for you have been injured?
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  24. If yes, please provide details
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  25. Have you previously been refused insurance or have had your insurance cancelled by an Insurer or have had special conditions, increased premiums or increased excesses imposed on any policy of insurance by an Insurer?
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  26. If yes, please provide details
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  27. I/We declare all information given to be correct, 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.

  28. I/We agree with the above statement(*)
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  29. Anti-Spam
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  30. Submit