Liability Online Submission Important InformationPlease visit our appetite list BEFORE completing this form to ensure it's a risk we can consider. IF USING FOR CLEANERS PLEASE ENSURE YOU ALSO COMPLETE OUR CLEANERS ADDENDUM FOUND HERE. This form appears to work best with Google Chrome. This 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. 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). A PDF prop is also available on our website should you prefer https://edgeunderwriting.com.au/insurance/2020/05/Public-Products-Liability-Application.pdf. The InsuredStreet Address *Suburb *State *Post Code *Website *Business Description - Please fully explain the the Business activities *Start-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 * If you have not already done so, please visit our appetite list BEFORE pressing next to ensure it's a risk we can consider.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 Turnover into the following categoriesWholesaleRetailManufacturingService / Repairs / MaintenanceInstallationOther"Other" Description *Imports *The Insured does NOT import any productsThe Insured DOES import productsList of Imported Products *Annual Cost of Imported Products *Country where product(s) is/are made *Exports *The Insured does NOT export any productsThe Insured DOES export productsList of Exported Products *Value of products exported *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 *CoverExpiring Insurance *Existing cover IS in placeExisting cover is NOT in placeHolding Underwriter *Expiry Date *Renewal *Renewal IS being invitedRenewal is NOT being invitedHolding / Attacking *I am the holding brokerI am the attacking brokerDo you have a target premium? *This InsurancePlease provide details of the proposed coverProposed Inception Date *For 12 Months? *YesNoProposed Expiry Date *Limit of Liability *Goods in Care, Custody & ControlOptional Additional BenefitsAsbestos Liability (Occurrence)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)Asbestos Limit of Liability *Goods on Hook Sub-Limit *Total Goods in CCC Sub-Limit *Incidental PI Sub-Limit *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 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 exceeding 2 stories (internally or externally)The Insured DOES work at heights exceeding 2 stories (internally or externally)Please 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 (including activity and % of T/O) *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 *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 *Loss 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 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 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 hereI am also interesting in the following policiesCorporate TravelCyberGlueGlue LiteLEXi Legal ExpensesManagement LiabilityProfessional Indemnityselect none or as many as you likeCorporate Travel QuoteYou can obtain an instant indication HERECyber 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 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 licence *Submit to Edge