EDGE Online – GLUE New Business Important InformationPLEASE USE GOOGLE CHROME ONLY This is for stand-alone GLUE policies only (ie. where Edge does not write and/or is not being asked to quote the primary liability policy). If you would like us to quote the primary liability policy AND the GLUE, please go HERE The intent of this on-line application is to replace the need for a broker's full quote slip or a completed proposal form. It's interactive such that the questions asked match the answers given (eg. if not involved in the scaffold industry all the specific scaffold questions remain hidden!) This 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. 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 InsuredStreet Address *Suburb *State *Post Code *Website *Business DescriptionPlease fully explain the the Business activitiesStart-up *This is NOT a start-up / new businessThis IS a start-up / new businessNo. of years THIS business has been going *Please comment on previous relevant experience *FinancialsActuals (last 12 months)Turnover *Wageroll *No. of Employees *Estimates (next 12 months)Turnover *Wageroll *No. of Employees *T/O Split for S/Duty Purposes *100% of T/O comes from the home state/territory of the InsuredT/O comes from multiple states/territoriesACTNSWNTQLDSATASVICWAOverseasPlease split the estimated turnover into the following categoriesWholesaleRetailManufacturing / ImportingService / Repairs / MaintenanceInstallationOther"Other" Description *Imports *The Insured does NOT import any productsThe Insured DOES import productsExports to USA/Canada *The Insured does NOT export any products to USA/CanadaThe Insured DOES export products to USA/CanadaValue of products exported to USA/Canada *Contractors *The Insured does NOT engage any contractors or subcontractorsThe Insured DOES engage contractors or subcontractorsEstimated Annual Payments to contractors/subcontractors *Please describe the activities the contractors/subcontractors perform for the Insured *Labour Hire Personnel *The Insured does NOT engage any labour hire personnelThe Insured DOES engage labour hire personnelEstimated Annual Payments to Labour Hire personnel *Please describe the activities the Labour Hire personnel perform for the Insured *CoverGLUE InsuranceProposed Inception Date *For 12 Months? *YesNoProposed Expiry Date *GLUE Limit of Liability *Primary / Underlying InsurancesUnderlying Policy 1Cover *Insurer *Policy Number *Underlying Policy 1Limit of Liability *Expiry Date *GWP *Underlying Policy 2CoverInsurerPolicy NumberUnderlying Policy 2Limit of LiabilityExpiry DateGWPAdditional Underlying PoliciesWould you like to add more primary / underlying policies?Answer *NoYesUnderlying Policy 3CoverInsurerPolicy NumberUnderlying Policy 3Limit of LiabilityExpiry DateGWPUnderlying Policy 4CoverInsurerPolicy NumberUnderlying Policy 4Limit of LiabilityExpiry DateGWPUnderlying Policy 5CoverInsurerPolicy NumberUnderlying Policy 5Limit of LiabilityExpiry DateGWPUpload underlying insurance hereChoose FileNo file chosenDelete uploaded filePlease attach the policy schedule and policy wordingUpload underlying insurance hereChoose FileNo file chosenDelete uploaded filePlease attach the policy schedule and policy wordingUpload underlying insurance hereChoose FileNo file chosenDelete uploaded filePlease attach the policy schedule and policy wordingUpload underlying insurance hereChoose FileNo file chosenDelete uploaded filePlease attach the policy schedule and policy wordingUpload underlying insurance hereChoose FileNo file chosenDelete uploaded filePlease attach the policy schedule and policy wordingUpload underlying insurance hereChoose FileNo file chosenDelete uploaded filePlease attach the policy schedule and policy wordingUpload underlying insurance hereChoose FileNo file chosenDelete uploaded filePlease attach the policy schedule and policy wordingUpload underlying insurance hereChoose FileNo file chosenDelete uploaded filePlease attach the policy schedule and policy wordingSub-limitsList any Underlying Sub-limits that you wish us to mirror (ie. this has the effect of doubling the underlying sublimits)ItemSub-limitItemSub-limitItemSub-limitItemSub-limitItemSub-limitItemSub-limitItemSub-limitItemSub-limitHigher Hazard ActivitiesFees *The Insured DOES NOT charge separate fees for professional servicesThe Insured DOES charge separate fees for professional servicesPlease provide full details and confirm separate PI cover is in placeBlasting *Blasting is NOT undertakenBlasting IS undertakenPlease 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.Please provide full detailsDemolition *The Insured does NOT demolish structuresThe Insured DOES demolish structuresPlease 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 performedPlease provide full detailsScaffolding Activities *There is NO: Erecting, Dismantling or Hiring (out) of scaffolding systemsThere IS: Erecting, Dismantling or Hiring (out) of scaffolding systemsHot Works *'Hot Works' are NOT undertaken (ie. Welding | Cutting | Grinding)'Hot Works' ARE undertakenPlease provide full details including % split between on-site and off-site hot worksWorking at heights *The Insured does NOT work at heights > 25mThe Insured DOES work at heights > 25mPlease provide full detailsDrilling | 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)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:: 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 *QA & Risk ManagementQuality AssurancePlease 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?Risk ManagementAn 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 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 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. Please ExplainSCAFFOLD 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?Answer *NoYesPublic Seating / StandsIs there any work involving Public Seating, Stands, and/or Stages?Answer *NoYesInspectionIs there a documented inspection system, pre and post use / hire with written and photographic records kept?Answer *YesNoScafftagsIf you erect scaffolding systems, are "Sacfftags" always used?Answer *YesNoN/AInstructionsIf you dry hire or sell scaffolding systems or parts, are written instructions provided covering use, maintenance and safety?Answer *YesNoN/ATrainingDoes the Insured have a formal, written training process in place?Answer *YesNoLoss HistoryMove to last sectionAs you've advised this is a new / start-up business, please move directly to the last sectionPrevious Claims *In the last 5 years there has NOT been ANY liability claimsIn the last 5 years there has been liability claimsUninsured Losses *In the last 5 years there been NO uninsured liability lossesIn the last 5 years there HAS been uninsured liability lossesPlease provide full detailsKnown Circumstances *After the appropriate enquiries, there any 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 claimPlease provide full detailsYearAmount PaidAmount OutstandingTotal IncurredYearAmount PaidAmount OutstandingTotal IncurredYearAmount PaidAmount OutstandingTotal IncurredYearAmount PaidAmount OutstandingTotal IncurredYearAmount PaidAmount OutstandingTotal IncurredIndividual claims >$5k? *There is NO individual claim >$5k?There IS/ARE individual claim/s >$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) Instructions & 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 herePlease feel free to upload any additional attachments hereChoose FileNo file chosenDelete uploaded fileBrokers Name *Enter your name hereBroking House *Brokers Email Address *Brokers Phone Number *Are you or your broking house an AR? *NoYesName of broking house who holds the broking licence *Submit to Edge