Commercial Products Fact Find -TFIB

Collect Details
Contact Name details*
Account Name*
Company Number*
Established Date*

DayMonthYear
Date
Annual Turnover*

Number of Employees*

	Casual	Part-time	Full-time
Employees
Directors
Principals, partners and directors
Qualified professionals
Other technical staff
Administrative and clerical staff
Contractors
Volunteers
Other

List of all activities/services provided*
Current Insurer*
Current Renewal Date*

DayMonthYear
Date

Statutory Liability
Statutory Liability
Retroactive Type

DateUnlimited
Retroactive Date

DayMonthYear
Date
Limit of Indemnity
Specify General Indemnity Limit ($)

Employers Liability
Employers Liability
Retroactive Type

DateUnlimited
Retroactive Date

DayMonthYear
Date
Limit of Indemnity
Specify General Indemnity Limit ($)

Carriers Liability
Period of Insurance
From

DayMonthYear
Date
To

DayMonthYear
Date
1. The Cover

Limits of Indemnity
1.1 Any one 'unit of goods' as defined in Section 259(4) of the Contract and Commercial Law Act 2017
1.2 Any one conveyance owned or operated by the Insured
1.3 Any one accident, i.e. any one occurrence or all occurrences of a series consequent on, or attributable to,one source or original cause.
Are you prepared to carry a larger excess than the standard $250?

YesNo
If 'Yes', please specify the amount*
Excluded products The policy excludes liability for loss to:
1. jewellery, gold and silver articles, precious stones, bullion, cash, banknotes, deeds, bonds, bills of exchange and other documents representing money,
2. aircraft of any kind including helicopters,
3. accessories in or on any aircraft or helicopter,
4. household goods and personal effects carried for the purpose of household removal, unless the insured did not know, and could not reasonably have known, that household or personal effects were being, or were to be, carried,
5. office furniture carried for the purpose of office removal, unless the insured did not know, and could not reasonably have known, that office furniture was being, or was to be carried,
6. tobacco or tobacco products.
Declared value risk or declared terms
1.4 Do you require an extension of cover for any ‘declared value’ or ‘declared terms’ contracts, as defined by the Contract and Commercial Law Act 2017?

YesNo
If 'Yes' please attach copies of contracts

Cancelof
2. The Business
2.1 State the number and type(s) of vehicles operated by you:*

2.2 Please tick if you carry any of the following:

	Never	Occassionally	Frequently
Machinery
Glass, china, etc
Livestock
Refrigerated Goods
Whiteware, eg. Refrigerators
Brown goods, eg. TV's
Vegetables and Fruit

2.3 State the main type of goods carried
2.4 State the number of years the business has been established

2.5 What percentage of freight earnings are derived from:

	% of total
2.5.1 Urban Deliveries
2.5.2 Inter-city movements within North or South Island
2.5.3 Inter-island movements
2.5.4 Rural deliveries

2.6 State the estimated gross income from your activities which are covered under the Contract

2.6 Indicate the estimated percentage of your gross income from contracts where you act as:

	%
2.6.1 Contracting carrier not actually carrying
2.6.2 The first actual carrier in the transit
2.6.3 An intermediate carrier in the transit
2.6.4 The final carrier in the transit

2.7 State in terms of the Contract and Commercial Law Act 2017, the estimated percentage of gross annual income you contract:

	% of gross income
2.7.1 At ‘Owners Risk’
2.7.2 At ‘Limited Carrier’s Risk'
2.7.3 At ‘Declared Value Risk'
2.7.4 On 'Declared Terms'

2.8 Consignment notes: Attach a copy for each type of carriage contract. If a consignment note is not issued for each contract, please detail how the terms of carriage are advised to clients.

Cancelof
3.1 Do you employ subcontractors? (Please tick)

YesNo
If ‘Yes’, what percentage of your Gross Freight relates to sub-contractor loads?
3.2 If sub-contractors are employed, is your liability as principal to be covered whilst goods are in the custody

YesNo

Contractors Plant & Machinery
Gross Vehicle Weight: For trucks, trailers, mobile plant over 3,500kgs, please provide the gross laden weight (GLW Gross laden weight means the vehicle weight plus load capacity.

Sum Insured: The Sum Insured must include all accessories and ancillary equipment fixed to or used with the insured item and must be no less than market value. GST does not need to be added.

Type a question

	Make, Model and description	Year of manufacture	Registration number (if road registered) or other identification	Gross laden weight	Sum Insured
1
2
3
4
5
6
7
8
9
10

Tick if required

	Tick	Where taken, specify which tems (if all items, show 'All')
Agreed Value
Breakdown
Damage to property being lifted
Excess for windscreens and window glass
Finance payment protection
Hired out insured property (dry hire)
Hoists and hydraulic rams
Ingestion or entanglement
Loss of revenue or additional cost of working
Multi lifting
Tools
Tools (employees)
Tyre and track damage

Will any items be used for forestry work or logging or timber extraction in forests?

YesNo
If 'Yes' please give full details below
Will any items be used in mines or quarries?

YesNo
If 'Yes' please give full details below
Are any items used or designed to be used underground or have attachments used or designed

YesNo
If 'Yes' please give full details below
Do any items carry toxic chemicals, acids, explosives or other items considered dangerous?

YesNo
If 'Yes' please give full details below
Are any items hired out without your operator?

YesNo
If 'Yes' please give full details below
Are any items designed to be operated as a crane?

YesNo
If 'Yes' please give full details below
Is any item fitted with any fire suppression systems, anti-theft devices or fire extinguishers?

YesNo
If 'Yes' please give full details below
Has any item been altered from the manufacturer’s original specifications?

YesNo
If 'Yes' please give full details below
Is any item used in high country, mountainous or inaccessible terrain?

YesNo
If 'Yes' please give full details below
Will any item be used airside at an airport?

YesNo
If 'Yes' please give full details below
Where is the insured property normally housed when not in use? (i.e. locked garage, locked yard, etc
Does any item require the operator to have a specific license and/or receive specific training to ensure

YesNo
If ‘Yes’, please give full details of the operator/s who hold the required licenses or have completed the required training below, and/or on a separate page.

Marine Cargo
Imports
Exports
NZ sendings

Basis of Valuation for Insurance Purposes

	%	or other
Imports (cost, freight plus:)
Exports (cost, insurance freight plus:)
NZ sendings (invoice cost, insurance plus incidental charges:)
Others

Estimated value of goods to be insured annually

	Actual last 12 months	Estimated next 12 months
Imports (cost, freight plus:)
Exports
NZ Sendings
Policy plusage
Sellers interest
Duty

Method of declaration

IndividualMonthly ScheduleAnnual adjustable

Type a question

	Sea (%)	Air (%)	Post (%)	Road/Rail (%)	Own Vehicle (%)
Import
Exports
NZ sendings

Transits to be insured

	From	To
Imports
Exports

NZ Sendings - Contract of carriage terms

	%
Limited carriers risk
At owners risk
Own vehicles

Details of goods to be insured
- Don’t underinsure. Use current market value as the basis for insuring your goods. When the sum insured is less than current value youmay become self insured for a part of any claim you make. example; if you underinsure by 50% any claim will be reduced by half plusthe amount of your excess.
- Where we agree to insure goods for their cost of replacement, use the new replacement value figure when arriving at your sum insured.
- Limited conditions of insurance cover will apply to goods shipped on deck if they are not packed in fully enclosed Iso shipping containersof solid wall and roof construction.
- Limited conditions of insurance will apply to shipments carried on deck (unless shipped as protected stowage) and not packed in fullyenclosed Iso containers of solid wall and roof construction
Goods to be Insured*
Additional clauses and warranties required

Duty of Disclosure
Duty of Disclosure

Have you or any partner(s) or director(s) of the business:

	Yes	No
Ever had an insurance policy cancelled, declined or terms imposed?
Ever been declared bankrupt?
Ever been involved in a company or business which became insolvent or subject to any form of insolvency administration (e.g. liquidation or receivership)?
Been convicted of any criminal offence within the past 5 years (other than minor traffic convictions)?
Been liable for any civil offence or pecuniary penalty (exceeding $5,000)?
Any other matters you should disclose?
Do you want to provide any important information for the insurer?

Claims
Any claims in the last 3 years?*

YesNo
Number of Claims?
Policy Type
Date of Loss

DayMonthYear
Date
What was the total cost of the claim?
Description
Claims History Attachment

Cancelof
General Liability
Statutory Liability
Professional Indemnity
Cyber Liability
Material Damage
Commercial Motor
Employers Liability
Management Liability
Business Interruption
Period of Insurance Required

DayMonthYear
Date
Renewal Date

DayMonthYear
Date
First Name
Last Name
Role
Date of Birth

DayMonthYear
Date
Signature

Clear
Date

DayMonthYear
Date
Should be Empty:

	Last financial year (actual) $	Current financial year (projected) $	Next financial year (estimated) $
New Zealand
Australia
Pacific Islands
Asia
UK & Europe
USA & Canada

	Name of potential claimant	Brief description of matter	Estimate of potential liability($)	Has claim been previously notified? If ‘Yes’, when??
1
2
3
4

Commercial Products Fact Find

Collect Details

Liabilities

General Liability

Hot Work

Hazardous Substances

Product Details

Coverages

Optional Extensions

Statutory Liability

Employers Liability

Management Liability

Business Details

Locations

Product Details

Professional Indemnity

Personnel by category

Business Details

Financial Information

Principals, Partners and Directors

Professional bodies

Other Details

Supply Details

Large Contractual Agreements

Written Reports

Consultant, Subcontractor, Agent Details

Prior Insurance History

Potential Claims

Cyber Liability

Risk Management

Vendor Management

Claims and Circumstances

Material Damage

Location One

Material damage coverages

Buildings

Stock

Contents

Seasonal Stock Increase

Location Two

Material damage coverages

Buildings

Stock

Contents

Seasonal Stock Increase

Location Three

Material damage coverages

Buildings

Stock

Contents

Seasonal Stock Increase

Location Four

Material damage coverages

Buildings

Stock

Contents

Seasonal Stock Increase

Location Five

Material damage coverages

Buildings

Stock

Contents

Seasonal Stock Increase

Location Six

Material damage coverages

Buildings

Stock

Contents

Seasonal Stock Increase

Business Interruption

Optional Extensions

Commercial Motor

Vehicle Details #1

Interested Parties

Optional Extensions

Vehicle Details #2

Interested Parties

Optional Extensions

Vehicle Details #3

Interested Parties