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Ausglass

Liability Insurance Questionnaire

The Ausglass members liability policy has been arranged to provide the members with a high quality public & products liability insurance. The policy can cover Glass craft practices. Cover includes members who practice their craft, teach craft on an individual basis to small groups of ten (10) or less people, or demonstrate or exhibit to the public.

To apply, please complete the following form.
Cover is not automatic or guaranteed. We will contact you if there are queries on your application.

Fields designated in RED require completion

PERSONAL DETAILS
Contact
Email Address
Phone
Fax
Mobile Phone
Preferred method of contact
Email   Phone   Fax
BUSINESS DETAILS
Company name

Trade name

ABN
Proprietor Name

Proprietor Name

Taxable Percentage Claimed

Postal address
Suburb/Town
State
Postcode
Situation of premises/shop/offices (if same as above leave blank)
Address
Suburb/Town
State
Postcode
Period of Insurance
Cover can only commence once full payment and completed application have been received and approved
From (1st June)  
4pm
To (31st May)  
4pm
Limit of Indemnity Required (Public and Products Liability)
 $10,000,000   $20,000,000
Note: Limit of Liability: $10,000,000 Public and Products Liability
Please describe principal art form
Description artistic and art related business activities undertaken:
Relevant Credentials (Diploma/Degree/Dip Ed etc)
OTHER DETAILS
Description of venue(s) where activities are conducted:
Estimated number per annum of   
Public exhibitions
Workshops
Estimated number of attendees   Estimated number of attendees  
Per exhibition
All exhibitions
Per workshop
All workshops
Type of Exhibition Type of Workshop
Do you engage Sub-Contractors and/or Service Providers?
Yes   No
If yes, state details
Number of Tutors/Entertainers Number of Other StaffTurnover (last 12 mths) Turnover (Estimate for next 12 mths)
Are there any hazardous activities associated with your business?
Yes    No
If yes, state details
Construction of the premises:  
WallsFloors RoofNo. of Storeys
Age of Building   Fire Protection and Security Details
CONTRACTUAL LIABILITY
Coverage for Liability assumed under agreement or contract will be limited to lease liability or liability assumed under a warranty of fitness or quality as regards your products.
Do you assume Liability under contract or hold others harmless (other than lease liability)?
Yes   No
If yes, please provide details (other than lease liability)
GENERAL DETAILS
Have you or anyone this policy is to cover (in the past 5 years)
1. Made any claim(s) on an insurer for loss or damage?
Yes   No
If yes, please supply details.
2. Had any insurance declined or cancelled, proposal/application rejected, renewal refused, claim rejected, special conditions or excess imposed by an insurer?
Yes   No
If yes, please supply details.
3. Suffered any loss or damage which would have been covered by the proposed insurance policy?
Yes   No
If yes, please supply details.
4. Have you or any partner(s) or director(s) of the business ever been declared bankrupt?
Yes   No
If yes, please supply details.
5. Ever been involved in a company or business which became insolvent or subject to any form of insolvency or administration (e.g. liquidation or receivership)?
Yes   No
If yes, please supply details.
6. Been convicted of any criminal offence within the past 5 years (other than minor traffic convictions)?
Yes   No
If yes, please supply details.
7. Been liable for any civil offence or pecuniary penalty (exceeding $5,000)?
Yes   No
If yes, please supply details.
I have read the Duty of Disclosure (view)
Duty of Disclosure

In order to make an informed assessment of the risk and calculate the appropriate premium, your insurer needs information about the risk you are asking it to insure.

For this reason, before you enter into a contract of insurance, you have a duty under the Insurance Contracts Act 1984 to disclose to your insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer’s decision whether to accept the risk and, if so, on what terms. The duty also applies when you renew, extend, vary or reinstate a contract of insurance.

You do not have to disclose anything that:

  • Reduces the risk to be undertaken by the insurer;
  • Is common knowledge;
  • Your insurer knows, or in the ordinary course of its business, ought to know; or
  • If the insurer has waived your obligation to disclose.
If you do not comply with your duty of disclosure, your insurer may be entitled to reduce its liability in respect of a claim or may cancel your contract of insurance. If the non-disclosure was fraudulent, the insurer may be able to avoid (or cancel) the contract of insurance from its beginning. This would have the effect that you were never insured.

One important matter to be disclosed is the history of losses suffered by the person seeking insurance or any closely associated person or entity. As you are responsible for checking that you have made complete disclosure, we suggest that you keep an up to date record of all such losses and claims.

Signature
Title
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Member of National Insurance Brokers Association and Steadfast Group Limited

Australian Financial Services Licence No 237491 – General Insurance Broker

 

 

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