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Liability Insurance Questionnaire

Public & Products Liability insurance is available for most business operations. This policy will provide protection to you, where you have a liability at law for property damage &/or bodily injury to another person.

In order for City Rural Insurance Brokers to provide you with an Obligation Free Quote, please complete the following.

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
Proprietor Name

Proprietor Name
Postal address
 Suburb/Town
State
 Postcode
Situation of premises/shop/offices (if same as above leave blank)
Address
 Suburb/Town
State
 Postcode
Specific Occupation
Qualifications/Experience
Proposed Sum Insured   $10m   20m (Public & Products Liability)
OTHER DETAILS
(a) Does the business involve the sale and supply of goods?
Yes    No
If yes, state details
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(b) Does the business manufacture/modify/alter any product?
Yes    No
If yes, state details
(c) Does your business operate or visit any potentially high risk areas? (Such as Airports, Mining or Exploration Sites, Wineries, Petroleum Plants) Yes    No
If yes, state details
(d) Are any products IMPORTED by you / your business?
Yes   No
If yes state
Type of Goods     
Country of origin     Approx value 
Type of Goods     
Country of origin     Approx value 
Type of Goods     
Country of origin     Approx value 
(e) Are any products EXPORTED by you / your business?
Yes   No
If yes state
Type of Goods     
Destination     Approx value 
Type of Goods     
Destination     Approx value 
Type of Goods     
Destination     Approx value 
Annual estimated turnover (sales)
 Employees wages  
Proprietors/Directors wages 
 Number of people in business at any one time
Does business engage sub contractors?
Yes   No 		Estimated total value of sub contractors
Type of work sub contracted to others
Are unregistered vehicles used in business?
Yes   No
If yes, state details
Is cover required for Goods in Physical & Legal Control?   
Yes   No
If yes, state type of goods and amount of cover required
Previous losses/claims for Public Liability
Previous Liability Insurer
Expiry date
How many years have you had experience in this type of business
years
Have you recently completed any Business Management Courses or a New Enterprise Incentive Scheme (NEIS)?
Yes   No
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.
Have you or any partner(s) or director(s) of the business
4. 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
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Australian Financial Services Licence No 237491 – General Insurance Broker

 

 

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Australian Financial Services Licence No 237491

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