Liability Renewal Online Submission Important InformationWho is completing the form? *InsuredBrokerImportant Information for BrokerPLEASE USE GOOGLE CHROME ONLY 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 your 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).Important Information for InsuredPLEASE USE GOOGLE CHROME ONLY USEThe 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.PRIVACYEdge 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 DISCLOSUREBefore 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 somethingIf 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 QUESTIONSPlease answer all questions fully and ensure all information requested is providedThe InsuredExpiring Policy No. *0 / 11Expiry Date *Name of The InsuredStreet Address *Suburb *State *Post Code *Website *Do you need to make any changes to the Business Description shown on the expiring policy?NoYesPlease fully explain the changes in operations and advise the new Business descriptionFinancialsActuals (last 12 months)Turnover *Wageroll *No. of Employees *Estimates (next 12 months)Turnover *Wageroll *No. of Employees *Is any Turnover derived from outside of the home state (for Stamp Duty purposes)?NoYesPlease provide % or $ split per statePlease split the estimated turnover into the following categories ($ or %)Wholesale *Retail *Manufacturing *Service / Repairs / Maintenance *Installation *Other"Other" Description *ImportsIs any Turnover derived from Imports?NoYesPlease provide full details of imported products including: 1. value of goods & 2. Products Imported & 3. Countries Imported fromExportsIs any Turnover derived from Exports to USA/Canada?NoYesDetails of products Exported to to USA/Canada:Turnover *ContractorsIs the Insured likely to engage any contractors or subcontractors?NoYesEstimated Annual Payments to contractors/subcontractors *Please describe the activities the contractors/subcontractors perform for the Insured *Labour Hire PersonnelIs the Insured likely to engage any Labour Hire personnel?NoYesEstimated Annual Payments to Labour Hire personnel *Please describe the activities the Labour Hire personnel perform for the Insured *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 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 Public & Products Liability.IMPORTED PRODUCTS - QA & RISK MANAGEMENTAs you selected "Yes" to Imports, please answer the following specific questions in relation to the imported products: Are all the following statements true? 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 YesNoCONTRACTOR / SUBCONTRACTOR RISK MANAGEMENTAs you've selected "Yes" to contractors / subcontractors, please answer the following specific questions in relation to contractors / subcontractors: Are all the following statements true: 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. YesNoSCAFFOLD INDUSTRYIs the Insured involved in the erecting and/or dismantling of Scaffold?NoYesScaffold 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?NoYesHigher Hazard LocationsIs there any work on, at or around: Chemical sites; Petrol, Oil or Gas Production facilities; Aircraft or Watercraft; or Underground?NoYesInspectionIs there a documented inspection system, pre and post use / hire with written records kept?NoYesScafftagsIf you erect scaffolding systems, are "Sacfftags" always used?NoYesN/AInstructionsIf you dry hire or sell scaffolding systems or parts, are written instructions provided covering use, maintenance and safety?NoYesN/ATrainingDoes the Insured have a formal, written training process in place?NoYesASBESTOS AND/OR DEMOLITION INDUSTRYIs the Insured involved in any Asbestos or Demolition activities?NoYesBusiness Activities1. Please split the turnover into the following activities:a) Asbestos Removal Only (ie. excluding demolition)b) Demolition Only (ie. no asbestos)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 *Higher Hazard ActivitiesPlease advise if the Insured's activities are at, on, or involve the following:1. Airports / Bridges / Canals / Dams / Railway or Rail Track infrastructure / Shipyards / TunnelsAnswer *NoYes2. Chemical refineries / Mines or Quarries / Oil refineries / Oil refineriesAnswer *NoYes3. Critical or Safety Critical parts manufacturing (or importing) for the marine, automotive or aviation industriesAnswer *NoYes4. Excavation / Underpinning / Shoring Up / Piling / Working at heightsAnswer *NoYes5. Tunnelling / Vertical or Horizontal drilling / Hydraulic fracturing (hydrofracking)Answer *NoYes6. Hot Works (eg. cutting / welding /grinding)Answer *NoYes7. Power generation, distribution or infrastructureAnswer *NoYes8. Exports to, or manual work in USA or CanadaAnswer *NoYes9. Advice, design, or consultancy for a feeAnswer *NoYes10. Stand-alone project management (ie. managing projects for others) or stand alone supervision of other (eg construction management, supervising non-appointed contractors)Answer *NoYesAs you have answered Yes to 1 or more of the above, please provide full details:DetailsInstructions & Broker DeclarationDeclarationUnreported Claims / Known Circumstances (Edge Policy) After appropriate enquiry, is the Insured aware of any unreported claim or any other occurrence / circumstance which may develop into a claim under the expiring or the new policy?Answer *NoYesPlease provide full details *Claims (Previous Policies) 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?Answer *NoYesPlease provide full details *Material ChangesWith regards to the the Duty of Disclosure, are there any material changes to the nature of the risk being Insured?Answer *NoYesPlease provide full details *Any Other ChangesAre there any other changes to coverage or limits you would like us to consider for the forthcoming period of insurance?Answer *NoYesPlease provide full details *Please Confirm *I have explained the Duty of Disclosure to my clientI, the undernamed, 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 behalfThe information provided is a true, accurate and complete reflection of the answers provided to me by my clientMy Full Name *My Email Address *Brokers Name *Broking House *Brokers Email Address *Brokers Phone Number *Please provide any additional comments hereSubmit to Edge