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Online Sellers Quote Form

A quick form so we can learn more about your business and put forward an insurance proposal tailored to your needs. Estimated time 3-5 minutes. Any questions don't hesitate to give us a call on 1800 270 999.
Email: info@osi.insure Web: onlinesellersinsurance.com.au
LIABILITY INSURANCE FORM
BUSINESS NAME*
ADDRESS*
EMAIL*
example@example.com
PHONE NUMBER*
AUSTRALIAN BUSINESS NUMBER (ABN)? (Optional)
IS YOUR COMPANY REGISTERED FOR GST IN AUSTRALIA?
TYPE OF PRODUCT / PRODUCTS?
HOW DID YOU HEAR ABOUT US?
1. WHERE IS YOUR PRODUCT MANUFACTURED?
2. HAVE ALL PRODUCTS BEEN CHECKED TO FOLLOW MANUFACTURING INSTRUCTION CHECKLIST?
3. WHICH COUNTRIES DO YOU EXPORT TO?
4. DOES YOUR PRODUCT COMPLY TO AMAZON STANDARDS FOR ITS CATEGORY?
5. DO YOU CONDUCT ANY BUSINESS ACTIVITIES IN AUSTRALIA? DO YOU HAVE A WAREHOUSE OR OTHER TYPE OF PHYSICAL PREMISES WHERE YOU TRADE FROM?
IN RESPECT OF PRODUCTS EXPORTED TO NORTH AMERICA.

1. LIST ALL PRODUCTS THAT YOU EXPORT TO NORTH AMERICA TOGETHER WITH THE ESTIMATED TURNOVER OF EACH TYPE OF PRODUCT YOU ANTICIPATE WILL BE EXPORTED IN THE NEXT 12 MONTHS.
Product Description
$AUD
2. WEBSITE OR LINK TO YOUR AMAZON PAGE.
3. ARE YOU SELLING YOUR PRODUCTS IN ANY OTHER COUNTRIES? IF YES, PLEASE CONFIRM WHICH COUNTRIES AND THE SPLIT OF ANNUAL REVENUE PER COUNTRY.
4. DETAILS OF ANY QUALITY ASSURANCE IN PLACE
5. ARE ALL WARNINGS AND PRODUCT LABELLING HAVE BEEN REVIEWED BY LEGAL COUNSEL AND ARE IN LOCAL LANGUAGE OF WHERE THEY ARE BEING EXPORTED TO?
6. ARE ANY OF YOUR PRODUCTS INTENDED TO BE USED AS COMPONENTS IN OTHER PRODUCTS. IF SO, GIVE DETAILS.
Component name/ description
End product and use
7. ARE YOUR PRODUCTS SUBJECT TO ANY FORM OF PROCESSING, REPACKING OR ASSEMBLY IN NORTH AMERICA PRIOR TO BEING SOLD TO THE CONSUMER? IF YES, PLEASE GIVE DETAILS.
8. WHAT PERCENTAGE OF YOUR TOTAL TURNOVER IS DERIVED FROM EXPORTS TO NORTH AMERICA?
Vendors endorsement i.e. where you have agreed to arrange products

liability cover for your agent/ vendor/manufacturer

9. DO YOU SIGN OR AGREE TO ANY OF THE FOLLOWING IN RELATION TO YOUR CUSTOMERS OR AGENTS IN NORTH AMERICA?

	Yes or No
Hold harmless agreements
Contractual indenmnities
Vendors endorsement, i.e. when you have agreed to arrange products liability cover for your agent / vendor / manufacturer.

IF YOU HAVE RESPONDED “YES”TO ANY OF THE ABOVE, PLEASE PROVIDE DETAILS BELOW
10. DO YOU HAVE ANY PERMANENT REPRESENTATION IN NORTH AMERICA E.G. INCORPORATED SUBSIDIARY/ ASSOCIATED COMPANY, IMPORT AGENTS, PERSONS OR FIRMS HOLDING POWER OF ATTORNEY, EMPLOYEES ETC. IF SO, PLEASE PROVIDE DETAILS BELOW
11. PLEASE PROVIDE DETAILS AS TO HOW YOU ENSURE THAT YOUR PRODUCTS MEET OR EXCEED US FEDERAL REGULATIONS AND STATE LEGISLATIVE/LEGAL REQUIREMENTS REGARDING SAFETY, HYGIENE, ADDITIVES, IMPURITIES, MATERIALS, LABELLING, WARNINGS ETC.
12. ARE YOU LIVE ON AMAZON? IF NOT WHEN DO YOU THINK YOU WILL BE LIVE ON AMAZON?
Estimated Total Annual Turnover
Any Employees / Any Subcontractors
SIGNATURE

Clear
FULL NAME
DATE

MonthDayYear
Date
DUTY OF DISCLOSURE

It is essential that you comply with your duty of disclosure as the Insurance Company may been entitled to deny a claim, reduce it’s liability under the contract of insurance or cancel the contract from its beginning.

Please answer the following questions.

	Yes	No
Has an insurer with respect to any policy you've held (a) previously refused to renew, cancelled or terminated a policy of insurance.
(b) imposed special or restrictive conditions, increased excess, or premium.

Have you or any other person included as insured.

	Yes	No
Made any claims in the last 5 years on any insurance policy?
Had a claim refused or rejected by an Insurer on any insurance policy?
Been convicted of a criminal offence?
Been placed into administration, receivership, liquidation or bankruptcy?
Had any convictions for driving under the influence of alcohol or drugs, or had a license cancelled or suspended in the last 5 years?
Have anything else to declared under the duty of disclosure?

IF YOU HAVE TICKED “YES” TO ANY QUESTION PLEASE PROVIDE RELEVANT DETAILS BELOW
COMPLETED / CONFIRMATION BY THE INSURED
SIGNATURE

Clear
FULL NAME
DATE

MonthDayYear
Date
ONLINE SELLERS INSURANCE PTY LTD (CAR 462886) ABN 76 625 227 394 AUTHORISED REPRESENTATIVE FOR COMMUNITY BROKER NETWORK PTY LTD | ABN: 60 096 916 184 | ACN: 096 916 184 | AFSL 233750
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Online Sellers Quote Form

LIABILITY INSURANCE FORM

DUTY OF DISCLOSURE

COMPLETED / CONFIRMATION BY THE INSURED