Contractor Documents

1

This document allows contractors to supply Northpoint with evidence of sufficient insurance and public liability coverage for conducting designated works at our sites. It is a Northpoint requirement that you maintain current and suitable insurance / public liability coverage and licensing (where applicable) for tasks undertaken on our sites. Please complete the following statement with copies of your policies. Any queries contact Northpoint HSEC on 0457 749 180 or email hsec@northpoint.com.au

Company Name

ABN

2

Email

example@example.com

3

Phone Number

Area Code

Phone Number

4

Business Address

5

Contact Name

6

Service(s) provided to Northpoint

7

Upload Insurance Documents

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

8

Workers compensation

Policy Number

Sum insured for:

9

Workers Compensation Details

Name of Insurer

Period of Insurance

10

Public Liability Insurance:

Name of Insurer:

Period of Insurance:

11

Public Liability Details

Policy Number:

Sum insured for:

12

Professional Indemnity Insurance

Name of Insurer:

Period of Insurance:

13

Professional Indemnity Details

Policy Number:

Sum insured for:

14

SAFETY MANAGEMENT INFORMATION:Please upload any other documents in support of the tasks that you will undertake, such as: (Trade Licences, JSAs, SWMS, Risk Assessments, SOPs, High Risk Works Licence)

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

15

CONTRACTORS EMPLOYEE DETAILS:

Name, Qualification/licence & Expiry Date.

16

Will sub-contractors be engaged?

YESNO

17

CONTRACTORS EMPLOYEE DETAILS:If Sub-Contractors are engaged, please complete the following table.

Name, Qualification/licence & Expiry Date.

18

I declare the information provided by myself with respect to insurance coverage/licensing information is true and correct and I will not undertake any work at Northpoint sites without the insurance cover/licensing (where applicable) or without notifying the Northpoint HSEC Officer of any alterations to the policies listed above. I also undertake to ensure the ongoing currency of insurance policies and licensing (where applicable).

19

Signature

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