Liability Renewal Online Submission Important InformationThis form has been designed so that you can easily complete it from your records, or by you with your client over the phone, or by you when you visit them during the pre-renewal meeting. A full copy of the answers will be automatically emailed to you upon completion and you are welcome to forward this to your client for their signature if required (we do not require this).The InsuredExpiring Policy Number *Expiry Date *Name of the Insured *Street Address *Suburb *StateACTNSWNTQLDSATASVICWAPost Code *Website *E.g. http://example.comBusiness Description - Please fully explain the the Business activities *No. of years THIS business has been going *FinancialsActualsActuals (last 12 months)Act. Turnover *Act. Wageroll *Act. No. of Employees *EstimatesEstimates (next 12 months)Est. Turnover *Est. Wageroll *Est. No. of Employees *Turnover split for Stamp Duty Purposes (only complete the states / territories required)ACT %NSW %NT %QLD %SA %TAS %VIC %WA %Overseas %Imports / ExportsDoes the Insured import any products or components from overseas? *YesNoList of Imported Products *Annual Cost of Imported Products *Country where product(s) is/are made *Does the Insured export any products? *YesNoList of Exported Products *Value of products exported *Contractors / Labour Hire EmployeesDoes the Insured engage ANY contractors or subcontractors? *YesNoEstimated Annual Payments to contractors/subcontractors *Please describe the activities the contractors/subcontractors perform for the Insured *Does the Insured engage ANY labour hire personnel from labour hire companies? *YesNoEstimated Annual Payments to Labour Hire personnel *Please describe the activities the Labour Hire personnel perform for the Insured *Is there ANY internal labour hire / cross hire within the company group? *YesNoEstimated Annual Payments to internal cross hire employees *CoverLimit of Liability Required for the renewal *Goods in Care, Custody & ControlOptional Additional BenefitsOptional Additional BenefitsContractual Liability (Blanket Basis)Principles as Additional Insured & Waiver of Subrogation (blanket basis)Goods on HookIncreased Goods in Care, Custody & ControlIncidental PINegligent Loss of KeysRectification of Faulty WorkmanshipRip & TearStatutory LiabilityUnmanned Air Vehicles (Drones / UAV's)Goods on Hook Sub-Limit *$50,000$100,000$250,000$500,000$1,000,000Total Goods in CCC Sub-Limit *Incidental PI Sublimit *$250,000$500,000$1,000,000$2,000,000$5,000,000$10,000,000Rectification of Faulty Workmanship Sub-Limit *$25,000$50,000Rip & Tear Sub-Limit *$250,000$500,000Statutory Liability Sub-Limit *$500,000$1,000,000WARNING: You've appear to have selected the Contractual Liability extension but not the Principals as additional Insureds/Waiver extension. Normally these go together as when accepting the liability of others under contracts the Insured is normally also required to have the Principal as an additional Insured and waive their rights of subrogation in favour of the Principal? Higher Hazard ActivitiesFees *The Insured DOES NOT charge separate fees for professional servicesThe Insured DOES charge separate fees for professional servicesFees *Please provide full details and confirm separate PI cover is in placeBlasting *Blasting is NOT undertakenBlasting IS undertakenBlastingPlease note that upon submission we may need to obtain some additional information regarding their blasting activitiesCritical Parts *Safety / Critical parts are NOT imported/manufactured for marine, automotive or aviation industries?Safety / Critical parts ARE imported/manufactured for marine, automotive or aviation industries?Safety / critical parts are defined as: A part, assembly, installation, or production system with one or more essential characteristics that, if not conforming to the design data or quality requirements, would result in an unsafe condition that could cause loss or serious damage to the end item or major components, loss of control, or serious injury.Critical Parts *Please provide full detailsDemolition *The Insured does NOT demolish structuresThe Insured DOES demolish structuresDemolition *Please provide full details including heights of structures demolished (average and maximum) and details of any non-hand-tool-machinery usedExcavation, Underpinning, Shoring Up or Piling *There is NO: Excavation, Underpinning, Shoring Up or Piling performedThere IS: Excavation, Underpinning, Shoring Up or Piling performedExcavation, Underpinning, Shoring Up or Piling *Please provide full detailsScaffolding Activities *There is NO: Erecting, Dismantling or Hiring (out) of scaffolding systemsThere IS: Erecting, Dismantling or Hiring (out) of scaffolding systemsIs the Insured in the cleaning industry? *YesNoHot Works *Hot Works are NOT undertaken (ie. Welding | Cutting | Grinding)Hot Works ARE undertakenHot Works *Please provide full details including % split between on-site and off-site hot worksWorking at heights *The Insured does NOT work at heights exceeding 2 stories (internally or externally)The Insured DOES work at heights exceeding 2 stories (internally or externally)Working at heights *Please provide T/O split (%) by the following heights: LOW RISE (Up to 2 storeys); MEDIUM RISE (3-9 Storeys); HIGH RISE (10+ Storeys)Drilling | Tunnelling | Fracking *The Insured is NOT involved in: Tunnelling, Vertical or Horizontal drilling or Hydraulic fracturing (fracking)The Insured IS involved in: Tunnelling, Vertical or Horizontal drilling or Hydraulic fracturing (fracking)Drilling | Tunnelling | Fracking *Please provide full detailsHigher Hazard Locations *The Insured's activities (or their contractors/subcontractors) are NOT conducted on, at or around ANY of the following:The Insured's activities (or their contractors/subcontractors) ARE conducted on, at or around ONE OR MORE of the following:Higher Hazard Locations Airports | Bridges | Canals | Dams | Railway or Rail Track infrastructure | Shipyards | Tunnels Chemical refineries | Mines or Quarries | Oil refineries | Oil refineries Power generation or distribution infrastructure (including power stations, poles & lines) Off Shore | Underground | Overseas? Please provide full details (including activity and % of T/O) *QA & Risk ManagementHas the Insured made any improvements to their QA or Risk Management over the past policy period?YesNoPlease provide details of improvements made *Has the insured EVER been subject to a WorkSafe (or equivalent): investigation, had a work improvement order issued, or been fined or convicted of any OH&S breach *YesNoInvestigations / Fines Penalties: *Please provide full detailsHOT WORKS RISK MANAGEMENT *Please provide full details of how the Insured complies with the relevant Hot Works Australian StandardsIMPORTED PRODUCTS QA & RISK MANAGEMENT *ALL the following statements ARE trueNOT all of the following statements are trueStatements of Fact The Insured has arranged independent testing through an internationally recognised body (such as CSIRO / SAI Global / SAA Approvals) to ensure the products meet the required Australian Standard; and Where required, products are labelled with all applicable product safety warnings; and Where required, the products are provided with clear instructions and in English; and All imported products are easily identifiable via batch and bar code systems; and The Insured has a written quality assurance plan for the imported products; and The Insured maintains full rights of recovery against the overseas manufacturers/suppliers Imported Products *Please ExplainCONTRACTOR / SUBCONTRACTOR RISK MANAGEMENT *ALL the following statements ARE trueNOT all of the following statements are trueStatements of FactWritten Agreements There are written agreements in place with all contractors / subcontractors; and Insurance Requirements Under the agreement, all contractors / subcontractors are required to carry their own Public & Products Liability and Workers Compensation Insurances at the same levels as the Insured; and Under the agreement, the liability insurance for all contractors / subcontractors is required to contain a blanket Principal's Indemnity extension or if not, the policy is required to be extended to note the Insured as Principal; and Under the agreement, but only if the contractors / subcontractors operate in a Workers Compensation underwritten state (ie. ACT, WA, NT, TAS),  the contractors / subcontractors Workers Compensation insurance is required to be extended to include Principals Indemnity + Waiver of Subrogation (Act Benefits & Common Law); and Insurance management The Insured has a written procedure to monitor the contractors / subcontractors insurances; and Suitability / Qualification management Where individual contractors / subcontractors are engaged and/or where the Insured is directly responsible for supervising the contractors/subcontractors, the Insured has a written process to assess the suitability, health/fitness and qualifications of the contractors/subcontractors. Contractors / Sub Contractors *Please ExplainAddendaNil Addenda neededPlease hit "Next" to move to Loss HistorySCAFFOLD INDUSTRY ADDENDUMPlease answer the following specific questions that relate to the Insured's scaffolding activities:Scaffold Activities1. Please split the turnover into the following activities (by %):Dry Hire / Supply only % *Manufacture % *Sales % *Erecting/Dismantling % *Height2. Please also advise the % of work performed at the following heights:Under 2 stories (<6.6m) % *2 - 5 stories (6.6m - 16.5m) % *5 - 10 stories (16.5m - 33m) % *>10 stories (>33m) % *Location3. Please advise the % of work performed at the following locations:CBD % *Non-CBD Domestic % *Non-CBD Commercial % *Second Hand SalesDoes the Insured ever sell second hand equipment?NoYesPublic Seating / StandsIs there any work involving Public Seating, Stands, and/or Stages?NoYesInspectionIs there a digital inspection system: pre and post use / hire with written and photographic records kept?, and for attendances to make alterations? YesNoScafftagsIf you erect scaffolding systems, are "Scaff tags" always used, AND is there a digital system for retaining Staff Tags?YesNoN/AInstructionsIf you dry hire or sell scaffolding systems or parts, are written instructions provided covering use, maintenance and safety?YesNoN/AIf you are erecting, do you have clear, written contracts with customers/clients setting out who is responsible for inspections and their frequency and/or who is authorised to make any alterations to scaffolding?YesNoN/ATrainingDoes the Insured have a formal, written training process in place?Answer *YesNoHandover CertificatesIf erecting, does the Insured retain Handover Certificates? Do they include the signature of the head contractor, and photos of the scaff tags?Answer *YesNoN/ABest Practice TechIs there any use of technology, such as IoT sensors or software, or CCTV to monitor scaffolding integrity or on-site safety?Answer *YesNoBest Practice Safety NetsIs there any use of safety nets?Answer *YesNoASBESTOS AND/OR DEMOLITION INDUSTRY ADDENDUMBusiness Activities1. Please split the turnover into the following activities:a) Asbestos Removal Only (ie. excluding demolition)c) Demolition with Asbestos Removald) Blastinge) Excavation / Earthmoving (excluding working underground)f) Piling / Shoring Up / Underpinningg) Working Undergroundh) Salvage Salesi) All OtherPlease provide full details of "All Other" Activities *CLEANING INDUSTRY ADDENDUMPlease answer the following specific questions that relate to the Insured's cleaning activities:Cleaning ActivitiesPlease split the estimated turnover (by %) in the the following activitiesCleaning Activities - A Bathroom Cleaning Including Tile & Grout Cleaning Builders Clean (External) Builders Clean (Internal) Car Washing & Detailing Carpet / Upholstery Protection (Residential & Commercial) Cinema Cleaning (Outside Business Hours) Crime Scene / Drug / Forensic Cleaning / Toxic Mould Curtain & Blind Cleaning Factories (Outside Business Hours or Office Area only During Hours) Lawn Mowing & Garden Maintenance Office Cleaning (Outside Business Hours) Residential: Bond / End of Lease Cleaning / Move Out Cleaning / Spring Cleaning / Renovation Cleans Residential Cleaning Residential Swimming Pools Retail Shop Cleaning (Outside Business Hours) Street Cleaning Washing & Ironing Services(Excluding Laundromats / Dry Cleaners) Window cleaning(Ground level commercial or up to 2 story residential) Cleaning Activities - B Body Corporate (Strata) Cleaning Chimney Cleaning (Residential) Doctors / Dentist Office Cleaning (Excluding Medical Waste) Factory Cleaning (Outside Business Hours) High Pressure Washing (External Walls, House Washing, Roof, Driveways & Pathways, Patios, Shade Sails, Fences, Mould Removal) Office Cleaning (During Business Hours) Rubbish Removal (Excluding Asbestos) Schools / Childcare Centres (Outside Business Hours) Shopping Centres / Common Mall / Arcades / (Outside Business Hours - same day as closing ie. After shops shut for the night only) Sports Leisure facilities / Gymnasiums (Outside Business Hours) Steam Cleaning Window Cleaning (above ground floor commercial & under 10m, or above second story residential & under 10m) Enter total % for Cleaning Activities - A *Enter total % for Cleaning Activities - B *Cleaning Activities - C Floor Polishing, Stripping or Resealing Gutter & Roof Cleaning (Excluding High Pressure) Hospitals / Medical Facilities / Old Age Homes (excluding Medical Waste) Public Toilet Cleaning (Outside Business Hours) Shopping Centres / Common Mall / Arcades / (Outside Business Hours - same day as opening ie. Before shops open for the day only) Window Cleaning (above 10m, or using an EWP, or using rope access) Cleaning Activities - D Clubs (eg. RSL / Leagues Clubs) (During Business Hours or if open 24/7) Medical Facilities & Hospital Cleaning (including Medical Waste) Public Toilet Cleaning (During Business Hours) Schools / Childcare Centres (During Business Hours) Shopping Centres / Common Mall / Arcades (During Business Hours) Sports Leisure facilities / Gymnasiums (During Business Hours) Enter total % for Cleaning Activities - C *Enter total % for Cleaning Activities - D *Are there ANY non-cleaning activities (eg. maintenance / construction / product sales /security) *YesNoProvide details of ALL non-cleaning activities along with the % of T/O for each *Are there immediate areas to the cleaning cordoned off during the work and is there appropriate, temporary signage erected? *YesNoWhat precautions are in place in lieu of the above? *For during hours cleaning, what wet weather procedures are in place? *Do they maintain a written incident log (reported incidents by staff, contractors or third parties – injuries, incidents or near misses)? *YesNoDo they maintain a written schedule of locations cleaned (showing information such as: name of venue, location, hrs cleaned, duties and CCTV details)? *YesNoLoss HistoryEDGE Policy - Unreported Claims / Known CircumstancesAfter appropriate enquiry, is the Insured aware of any unreported claim or any other occurrence / circumstance which may develop into a claim under the Liability policy?NoYesPlease provide full detailsPrevious Policies - New Claims / Known CircumstancesAfter appropriate enquiry, where Edge has not been on-risk for all of the past 5 years, has their been any late notifications (ie. in the last 12 months) that relate to the previous insurer(s)?NoYesPlease provide full detailsLegal Disputes (previous): *The Insured has NOT been involved in a commercial or legal dispute which incurred legal costsThe Insured HAS been involved in a commercial or legal dispute which incurred legal costsPlease provide full detailsLegal Disputes (known circumstances): * After appropriate enquiry, is the Insured is NOT aware of any matter which may develop into a dispute that is likely to incur legal costs After appropriate enquiry, is the Insured IS aware of a matter which may develop into a dispute that is likely to incur legal costsPlease provide full detailsInstructions & Broker DeclarationI hereby Declare that: *I have explained the Duty of Disclosure to my clientI also Declare that: *The information provided by me is a true, accurate and complete reflection of the answers provided to me by my clientPlease provide any additional comments hereI am also interesting in the following policiesCyberGlueGlue LiteLEXi Legal ExpensesManagement LiabilityProfessional Indemnityselect none or as many as you likeCyber QuotePlease download the application form HERE or if you already have a prop, please upload it belowGLUEPlease advise below the desired GLUE Limit of IndemnityGLUE LOIGLUE LitePlease advise below the desired GLUE Lite Limit of IndemnityGLUE Lite LOILEXi QuoteYou can obtain an instant indication HEREMLPlease download the application form HERE or if you already have a prop, please upload it belowPIPlease download the appropriate application form HERE or if you already have a prop, please upload it belowPlease feel free to upload any additional attachments hereChoose FileNo file chosenDelete uploaded filePlease feel free to upload any additional attachments hereChoose FileNo file chosenDelete uploaded filePlease feel free to upload any additional attachments hereChoose FileNo file chosenDelete uploaded fileBroker's (your) Name *Enter your name hereBroking House *The broking company you work forBroker's (your) Email Address *Broker's (your) Phone Number *Are you or your broking house an AR? *NoYesName of broking house who holds the AFSL *Submit to Edge