Incidental Asbestos Liability eForm – Edge Underwriting

Name of the Insured *

Street Address *

Suburb *

State

Post Code *

HTML

Turnover split for Stamp Duty Purposes

(only complete the states / territories required)

ACT % *

NSW% *

NT% *

QLD% *

SA% *

VIC% *

TAS% *

WA% *

Current Public Liability Base Premium *

Business Description - Please fully explain the Business activities *

Existing Cover *Existing cover IS in placeExisting cover is NOT in place

Holding Insurer *

Expiry Date *

Renewal *Renewal IS being invitedRenewal is NOT being invited

Please advise why renewal is not being invited *

Proposed Inception Date *

Proposed Expiry Date

From and to 4:00pm Local Standard Time at the address of the proposed Insured for a period of 12 months unless requested otherwise

I hereby Declare that: *I have explained the Duty of Disclosure to my client

And 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/requests here

Full name of the Broker completing this form *

AR / Broking House You Work For *

Broker's Email Address *

Broker's Phone NumberPlease include area code if not providing mobile number

Are you or your broking house an AR? *NoYes

Name of Broking House who holds the AFSL *

Important Information

A full copy of your answers will be automatically emailed to you upon hitting the submit button below. You are welcome to forward this to your client for their signature and for your records if required (we do not require this).