Public Liability Insurance Proposal

Period of Insurance

From Date

To Date (4.00PM)

Insured Details

Name of Insured (inc. all subsidiary companies)

Postal Address

P/Code

Description of Business

ABN

Business Phone

Fax

Mobile

Email *

Location of Premises

Situation 1 : Address

State

Postcode

Situation 2 : Address

State

Postcode

Partners / Directors

Partners/Director 1

Name

Years Experienced in Industry

Years Experienced as Directors

Partners/Director 2

Name

Years Experienced in Industry

Years Experienced as Directors

Partners/Director 3

Name

Years Experienced in Industry

Years Experienced as Directors

Are you a member of a security association?, if so please provide details:

** FIELDS MUST BE COMPLETED TO ENSURE PROMPT QUOTATION

Years Business Established:

**Number of security Staff: Full-time:

** Part-time:

**Actual Turnover for last year: $

** Estimated Turnover for this year: $

**Actual Wages for last year: $

** Estimated Wages for this year: $

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

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**Do you use sub-contractors?

Percentage of Activity Subcontracted (%)

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

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

Do sub-contractors have their own insurance?

If yes, note details of certificate of Insurance

Name of Insurer:

Limit of Indemnity:

Policy No:

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

Period Of Insurance

Last Year

This Year

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

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

Installation of security systems

Investigation

Service & maintenance of security systems

Static guarding eg. Business premises, shopping

Centres, banks, gate-houses

Mobile patrols

Responding to alarms

Cash carry

Use of Firearms

Use of Dogs

Body guarding

Debt collections

Traffic control

Education programmes, i.e. self defence etc

Fire arms training

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

Monitoring of alarms

Manufacture of security systems

Crowd Control

- Hotels

- Concerts

- Discos

- Entertainment venues

Other

If other, please provide details:

Cover

Limit of Liability

Extensions Tenants Liability
Products Liability
Property Owners Liability

Do You Require Errors & Omissions:

If so, for what activities:

Guard Dog Security

Do you provide guard dog security?

Total number of dogs?

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

Are dogs permanently under control of handler?

If no, please provide details:

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

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

Firearms

Do you use firearms?

If Yes, please state:

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

Number of guards licenced to use guns?

Number and type of firearms used?

Are firearms serviced each year?

How often is shooting practice undertaken each year and provide details

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

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

Batons

Do you use batons?

If yes, please state:

Number and type of batons used

Please provide details of training undertaken

Warning signs & Notices

Do you provide warning signs or notices?

If yes, please state:

a) Type of signs/notices

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

c) Do you display signs at minimum distances?

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

If Yes, please give details

If yes, please provide a copy of the contract:

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

If Yes, please give 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 special conditions?

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

Insurance Declaration and Claims History

Insured’s previous insurer

Expiry Date

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

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 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.

I / Weagree: Yes No

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Public Liability Insurance Proposal

Period of Insurance

Insured Details

Partners / Directors

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

Cover

Guard Dog Security

Firearms

Batons

Warning signs & Notices

Your Previous History

Insurance Declaration and Claims History

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