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Public Liability Insurance Proposal

Period of Insurance

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Insured Details

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Location of Premises

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Partners / Directors

Partners/Director 1

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Partners/Director 2

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Partners/Director 3

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** FIELDS MUST BE COMPLETED TO ENSURE PROMPT QUOTATION

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

**PLEASE ATTACH EVIDENCE OF THIS**

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If yes, note details of certificate of Insurance

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

Period Of Insurance

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

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Cover

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Guard Dog Security

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Firearms

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If Yes, please state:

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Are firearms serviced each year?

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Batons

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If yes, please state:

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Warning signs & Notices

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If yes, please state:

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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:

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Insurance Declaration and Claims History

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

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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.

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