Scaffolders Proposal Form

Scaffolders Combined Liability Proposal Form

Please fill out this form and we will get back to you as soon as possible.
Liablilty Cover Requirements
Period of cover Required (From)

DayMonthYear
Date
Period of cover Required (To)

DayMonthYear
Date
Current insurer
Current deductible
Expiry date of current insurance

DayMonthYear
Date
Number of years insured
Current Limit of Indemnity
Please enter an amount in $ value
Expiring Premium
Please enter an amount in $ value
Limit of Liability Required*

$5,000,000$10,000,000$20,000,000Other
Optional Excess*

$5,000$10,000
Company Information
Full Name of Insured*

First NameLast Name
ABN
Enter your 11 digit ABN
On What Date Was the Company First Established/Commenced Trading?

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState

Post Code

	This Year	Last Year
Total Annual Turnover ($AUD)
Payments to sub-contractors ($AUD)

What is the nature of work carried out by sub-contractors?
Are contractors/sub-contractors required to carry their own insurance for public liability?*

YesNo
Are contractors/sub-contractors required to carry their own insurance for workers compensation?*

YesNo
What procedures are in place to check that this is in place?

Total number of staff:*

Show percentage of work performed in each state:

Declaration

Your Duty of Disclosure
I confirm that:*

I understand that the duty of disclosure applies to all Insured(s). the answers are provided on behalf of all persons/entities comprising the Insured(s)I understand the questions in the proposal
Authorised Signatory

Clear
Name of Signatory

First NameLast Name
Date Signed

DayMonthYear
Date
Position
Your Email: (A copy of your submission will be sent here)
example@example.com
If we are requested to cancel the policy, we will charge the following short period rate premiums. We will hold you and or your insurance intermediary liable to pay these amounts:
- Within 1 month of inception: 25% of the quoted premium
- Within 2 months of inception: 20% of the quoted premium
- Within 3 months of inception: 15% of the quoted premium
Thereafter at terms to be agreed with underwriters.
Please fill out this from and we will get back to you as soon as possible. Or if it is urgent you can call our office during business hours on 1300 477 662.
Should be Empty:

Scaffolders Combined Liability Proposal Form