- Fire Installers -

Fire Installers Public Liability Insurance Proposal

Policy No.:

Quote No.:

Cover Note No.:

Client No.:

Period Insured

From Date

To Date (4.00PM)

Please Advise us:

Is your business registered?

What is your input Tax Credit? (%)

What is your ABN?

The Insured

Name of Insured (inc. all subsidiary)

Postal Address

Description of Business

Email address *

Private Phone

Business Phone

Mobile Phone

Fax

Location of Premises:

Situation1 : Address

State

Postcode

Situation2 : Address

State

Postcode

Other Parties to be noted on Schedule

Interest of Party

Partners/Directors

Name of Partners/Directors:

Background of Partners/Directors:

Are you a member of a fire Association, if so please provide details:

Date Established

Number of fire Staff:

Full-time:

Part-time:

Estimated Wages for the year: $

Estimated Turnover for the year: $

Period of Insurance:

To enable us to calculate the correct Stamp Duty applicable to your Policy, please indicate which states you operate
in and provide a turnover split for each state in the table below:

QLD (% of T/O)

NSW (% of T/O)

ACT (% of T/O)

VIC (% of T/O)

TAS (% of T/O)

SA (% of T/O)

WA (% of T/O)

NT (% of T/O)

Turnover

What percentage of turnover is derived from the following?

Retail / Sale of Equipment

Install / Service / Repair Sprinkler Systems

Install / Service / Repair Alarms

Install / Service / Repair Extinguishers

Install / Service / Repair Hoses & Hydrants

Install / Service / Repair C.C.T.V. & the like

Install / Service / Repair ATM Machines

Monitoring of Alarms & the like

Training (Please Describe)

Other

Total: 100%

Details:

Cover

Limit of Liability

Extensions

Do you require Errors and Omissions?

If so, for what activities:

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

Upload

Do you use sub-contractors?

If Yes, please state payments to and role of sub-contractors

Do sub-contractors have their own insurance?

If yes note details of certificate of Insurance:

Name of Insurer:

Limit of indemnity:

Policy No:

Do you provide warning signs or notices?

If yes, please state:

Types of Signs and Notices

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

c) Do you display signs at minimum distances?

Do you provide any indemnities, holdharmless conditions to any customers, suppliers or other parties?

If yes, please provide a copy of the contract.

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

If yes, please provide full details:

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?

Had any Insurer decline any claims submitted?

Had any Insurer decline any Proposals submitted?

Had any Insurer cancel or refuse to renew a Policy?

Had any Insurer require any increased premium or imposed ?

Ever been bankrupt?

Been convicted of or charged with any civil or criminal offence?

If you answered "Yes" to any of the above, please give details (or attach if insufficient space):

Insurance Declaration and Claims History

Insureds previous Insurer

Expiry Date

Detail all insurance claims made in the last five years together with any uninsured losses. Please include dates and amounts. (If insufficient room please upload seperate document)

Upload

Date of Loss

Type of Loss

Amount

Name of Insurer

Date of Loss

Type of Loss

Amount

Name of Insurer

Date of Loss

Type of Loss

Amount

Name of Insurer

Date of Loss

Type of Loss

Amount

Name of Insurer

Date of Loss

Type of Loss

Amount

Name of Insurer

Date of Loss

Type of Loss

Amount

Name of Insurer

Date of Loss

Type of Loss

Amount

Name of Insurer

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 informAction 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 thebasis of the contract hould a policy be issued and the Applicants acknowledge that the Proposal andattachments will be incorporated in the Policy.

I agree : Yes NO

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Fire Installers Public Liability Insurance Proposal

Period Insured

The Insured

Partners/Directors

Turnover

Cover

Your Previous History

Insurance Declaration and Claims History

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