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(Client Completed) Liability Insurance Application

Important Information and Your Duty of Disclosure

USE
This form tends to work best in Google Chrome.

The intent of this on-line application is to replace the need for a a completed proposal form.

A full copy of your answers will be automatically emailed to your broker and yourself upon completion.

PRIVACY
Edge is committed to the protection of your privacy and is bound by the National Privacy Principles for the handling of your information. Edge’s Privacy Policy can be viewed online by visiting our website (edgeunderwriting.com.au).

YOUR DUTY OF DISCLOSURE
Before you enter into an insurance contract, you have a duty to tell us anything that you know, or could reasonably be expected to know, may affect our decision to insure you and on what terms.

You have this duty until we agree to insure You.

You have the same duty before you renew, extend, vary or reinstate an insurance contract.

You do not need to tell us anything that:

reduces the risk We insure You for; or
is common knowledge; or
we know or should know as an insurer; or
we waive your duty to tell us about.

If you do not tell us something
If you do not tell us anything you are required to, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both.

If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed.

PLEASE ANSWER ALL QUESTIONS
Please answer all questions fully and ensure all information requested is provided. If you get stuck, please consult with your broker.

The Insured

Name of the Insured *

Street Address *

Suburb *

State

Post Code *

Website *E.g. http://example.com

Business Description - Please fully explain the the Business activities *

Is this a new venture for the Insured? *

YesNo

No. of years THIS business has been going *

Please comment on previous relevant experience / trade / qualifications (the more info the better!) *

Please visit our appetite list BEFORE pressing next to ensure it's a risk we can consider.

Financials

Actuals

Actuals (last 12 months)

Act. Turnover *

Act. Wageroll *

Act. No. of Employees *

Estimates

Estimates (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 %

Please split the Turnover into the following categories

Wholesale

Retail

Manufacturing

Service / Repairs / Maintenance

Installation

Other

"Other" Description *

Imports / Exports

Does the Insured import any products or components from overseas? *

YesNo

List of Imported Products *

Annual Cost of Imported Products *

Country where product(s) is/are made *

Does the Insured export any products? *

YesNo

List of Exported Products *

Value of products exported *

Contractors / Labour Hire Employees

Does the Insured engage ANY contractors or subcontractors? *

YesNo

Estimated 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? *

YesNo

Estimated 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? *

YesNo

Estimated Annual Payments to internal cross hire employees *

Cover

Is existing cover in place? *

YesNo

Expiring Cover

Holding Underwriter *

Expiry Date *

Is renewal being invited? *

YesNo

Holding / Attacking *

I am the holding brokerI am the attacking broker

Do you have a target premium? *

Uninsured *

This Insurance

Inception Date *

For 12 Months? *

YesNo

Proposed Expiry Date *

Limit of Liability *

Goods in Care, Custody & Control

Optional Additional Benefits

Contractual 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 *

Total Goods in CCC Sub-Limit *

Incidental PI Sublimit *

Rectification of Faulty Workmanship Sub-Limit *

Rip & Tear Sub-Limit *

Statutory Liability Sub-Limit *

WARNING: 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 Activities

Fees *

The Insured DOES NOT charge separate fees for professional servicesThe Insured DOES charge separate fees for professional services

Fees *Please provide full details and confirm separate PI cover is in place

Blasting *

Blasting is NOT undertakenBlasting IS undertaken

Blasting

Please note that upon submission we may need to obtain some additional information regarding their blasting activities

Critical 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 details

Demolition *

The Insured does NOT demolish structuresThe Insured DOES demolish structures

Demolition *Please provide full details including heights of structures demolished (average and maximum) and details of any non-hand-tool-machinery used

Excavation, Underpinning, Shoring Up or Piling *

There is NO: Excavation, Underpinning, Shoring Up or Piling performedThere IS: Excavation, Underpinning, Shoring Up or Piling performed

Excavation, Underpinning, Shoring Up or Piling *Please provide full details

Scaffolding Activities *

There is NO: Erecting, Dismantling or Hiring (out) of scaffolding systemsThere IS: Erecting, Dismantling or Hiring (out) of scaffolding systems

Is the Insured in the cleaning industry? *

YesNo

Hot Works *

Hot Works are NOT undertaken (ie. Welding | Cutting | Grinding)Hot Works ARE undertaken

Hot Works *Please provide full details including % split between on-site and off-site hot works

Working 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 details

Higher 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 Management

Quality Assurance

Please describe the Quality Assurance system the Insured operates under (if any) such as: IS09000 series | HACCP | OHS | ISO14000 series | SQF2000 etc. If none of these, does the Insured have a written quality assurance plan?

QA *

Risk Management

An Insured's Risk Management details are probably the most important details of all and greatly assist in our understanding of your client's overall exposure, including which bits they handle and which bits transfer to us. This can have a material impact on the premium and deductibles or could even be the difference between us accepting or declining a risk.

Please describe below what systems/processes/procedures the Insured has inplace to...

Identity,
Assess,
Control (avoid / reduce), and
Monitor & review

....risk, relevant to their Public & Products Liability exposure.

General Risk Management Details *Please provide any other general risk management details

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 *

YesNo

Investigations / Fines Penalties: *Please provide full details

HOT WORKS RISK MANAGEMENT *Please provide full details of how the Insured complies with the relevant Hot Works Australian Standards

IMPORTED PRODUCTS QA & RISK MANAGEMENT *

ALL the following statements ARE trueNOT all of the following statements are true

Statements 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 Explain

CONTRACTOR / SUBCONTRACTOR RISK MANAGEMENT *

ALL the following statements ARE trueNOT all of the following statements are true

Statements of Fact

Written 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 Explain

SCAFFOLD INDUSTRY ADDENDUM

Please answer the following specific questions that relate to the Insured's scaffolding activities:

Scaffold Activities

1. Please split the turnover into the following activities (by %):

Dry Hire / Supply only % *

Manufacture % *

Sales % *

Erecting/Dismantling % *

Height

2. 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) % *

Location

3. Please advise the % of work performed at the following locations:

CBD % *

Non-CBD Domestic % *

Non-CBD Commercial % *

Second Hand Sales

Does the Insured ever sell second hand equipment?

NoYes

Public Seating / Stands

Is there any work involving Public Seating, Stands, and/or Stages?

NoYes

Inspection

Is there a digital inspection system:

pre and post use / hire with written and photographic records kept?, and
for attendances to make alterations?

YesNo

Scafftags

If you erect scaffolding systems, are "Scaff tags" always used, AND is there a digital system for retaining Staff Tags?

YesNoN/A

Instructions

If you dry hire or sell scaffolding systems or parts, are written instructions provided covering use, maintenance and safety?

YesNoN/A

If 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/A

Training

Does the Insured have a formal, written training process in place?

Answer *

YesNo

Handover Certifcates

If erecting, does the Insured retain Handover Certificates? Do they include the signature of the head contractor, and photos of the scaff tags?

Answer *

YesNoN/A

Best Practice Tech

Is there any use of technology, such as IoT sensors or software, or CCTV to monitor scaffolding integrity or on-site safety?

Answer *

YesNo

Best Practice Safety Nets

Is there any use of safety nets?

Answer *

YesNo

Incident Reporting

Do they maintain an electronic incident log (reported incidents by staff, contractors or third parties – injuries, incidents or near misses)?

Answer *

YesNo

ASBESTOS AND/OR DEMOLITION INDUSTRY ADDENDUM

Business Activities

1. Please split the turnover into the following activities:

a) Asbestos Removal Only (ie. excluding demolition)

c) Demolition with Asbestos Removal

d) Blasting

e) Excavation / Earthmoving (excluding working underground)

f) Piling / Shoring Up / Underpinning

g) Working Underground

h) Salvage Sales

i) All Other

Please provide full details of "All Other" Activities *

CLEANING INDUSTRY ADDENDUM

Please answer the following specific questions that relate to the Insured's cleaning activities:

Cleaning Activities

Please split the estimated turnover (by %) in the the following activities

Cleaning 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)

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 - A *

Enter total % for Cleaning Activities - B *

Enter total % for Cleaning Activities - C *

Cleaning Activities - D

Clubs (eg. RSL / Leagues Clubs) (During Business Hours or if open 24/7)

Enter %Leave blank if N/A

Medical Facilities & Hospital Cleaning (including Medical Waste)

Enter %Leave blank if N/A

Public Toilet Cleaning (During Business Hours)

Enter %Leave blank if N/A

Schools / Childcare Centres (During Business Hours)

Enter %Leave blank if N/A

Shopping Centres / Common Mall / Arcades (During Business Hours)

Enter %Leave blank if N/A

Sports Leisure facilities / Gymnasiums (During Business Hours)

Enter %Leave blank if N/A

Are there ANY non-cleaning activities (eg. maintenance / construction / product sales /security) *

YesNo

Provide 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? *

YesNo

What precautions are in place in lieu of the above? *

For during hours cleaning, what wet weather procedures are in place? *

What precautions are in place for the safekeeping of keys (eg. digital lock boxes with limited access plus a sign out / sign in log)? *

Do they maintain an ELECTRONIC incident log (reported incidents by staff, contractors or third parties – injuries, incidents or near misses)? *

YesNo

Do they use a WAND system and have an ELECTRONIC system for retaining wand reports? *

YesNo

Do they maintain a written schedule of locations cleaned (showing information such as: name of venue, location, hrs cleaned, duties and CCTV details)? *

YesNo

Move to last section

As you've advised this is a new / start-up business, please move directly to the last section

Loss History

Previous Claims *

In the last 5 years there has NOT been ANY liability claimsIn the last 5 years there has been liability claims

Year

Amount Paid

Amount Outstanding

Total Incurred

Year

Amount Paid

Amount Outstanding

Total Incurred

Year

Amount Paid

Amount Outstanding

Total Incurred

Year

Amount Paid

Amount Outstanding

Total Incurred

Year

Amount Paid

Amount Outstanding

Total Incurred

Individual claims exceeding $5k? *

There is NO individual claim exceeding $5k?There IS/ARE individual claim/s exceeding $5k?

Please provide full details (including DOL | Circumstances | Cost | Remedial Action)

Repeat Claims *

There has NOT been more than 2 claims resulting from similar circumstances (eg. water damage | damage to underground services | trip & fall)There HAS been more than 2 claims resulting from similar circumstances (eg. water damage | damage to underground services | trip & fall)

Please provide full details (including DOL | Circumstances | Cost | Remedial Action)

Uninsured Losses *

In the last 5 years there been NO uninsured liability lossesIn the last 5 years there HAS been uninsured liability losses

Please provide full details

Known Circumstances *

After the appropriate enquiries, there are NO circumstances that are likely to lead to a liability claimAfter the appropriate enquiries, there ARE circumstances that are likely to lead to a liability claim

Known Circumstacnes *Please provide full details

Legal 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 costs

Please provide full details

Legal 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 costs

Please provide full details

Instructions & Broker Declaration

I hereby Declare that: *

I have explained the Duty of Disclosure to my client

I also Declare that: *

The information provided by me is a true, accurate and complete reflection of the answers provided to me by my client

Please provide any additional comments here

I am also interesting in the following policies

CyberGlueGlue LiteLEXi Legal ExpensesManagement LiabilityProfessional Indemnityselect none or as many as you like

Cyber Quote

Please download the application form HERE or if you already have a prop, please upload it below

GLUE

Please advise below the desired GLUE Limit of Indemnity

GLUE LOI

GLUE Lite

Please advise below the desired GLUE Lite Limit of Indemnity

GLUE Lite LOI

LEXi Quote

You can obtain an instant indication HERE

ML

Please download the application form HERE or if you already have a prop, please upload it below

PI

Please download the appropriate application form HERE or if you already have a prop, please upload it below

Please feel free to upload any additional attachments here

No file chosen

Please feel free to upload any additional attachments here

No file chosen

Please feel free to upload any additional attachments here

No file chosen

I, the under-named, hereby declare that: *

I understand my Duty of Disclosure shown at the beginning of this formall answers and statements made in this Application are true, correct and complete in every respectwhere any part(s) of the Application has been completed by others, I have checked their answers and confirm they are true, correct and complete in every respectI give permission for Edge Underwriting or the Insurer to collect or disclose any personal information relating to this insurance to/from any other insurers or insurance reference serviceshould any information given by me alter between the date of this form and the inception/renewal date of the insurance to which this application relates, I shall give immediately notice thereofI am authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this application and I complete this application form on their behalf

Your Full Name *The person completing this form

Your Title / Position *

Your Email Address *

Your Brokers Name *Enter your Broker's name here (the person you deal with)

Their Email Address *

The company they work for *