Public Liability

Public Liability Form

Please fill out all sections accurately to help us process your insurance application efficiently.
Application Name
Product
Your Name

First NameLast Name
E-mail
example@example.com
Mobile Number
Format: +61 400000000.
Liability Limit Required

Company Name
Trust Name
ABN
ACN
Company Type
Business Activities

Company Address
Suburb
Suburb
State
Postcode
Number of Employees
Annual Revenue

Do you engage with sub-contractors and/or Labour Hire?
How much will be paid to them over the next 12 months?
What type of activities will they be doing?

How many claims have you made in the last 5 years?
Claim 1

DayMonthYear
Date
Amount Paid Out
Description
Claim 2

DayMonthYear
Date
Amount Paid Out
Description
Claim 3

DayMonthYear
Date
Amount Paid Out
Description

Do you have any criminal convictions over the last 5 years?

Client Consent – General Insurance

I understand my broker may receive a commission from the insurer for arranging, renewing, or varying my insurance.

- Commission is usually 5–20% of the base premium.
- It is paid by the insurer, not added on top of my premium.
- It is included in the premium shown on quotes and invoices provided to me.

This commission covers the broker’s services in sourcing, arranging, and managing my insurance.

This is a legal requirement under the Corporations Act 2001 (specifically the conflicted remuneration provisions in Part 7.7A) and upcoming Quality of Advice reforms.

I consent to my broker receiving this commission.
Name

First NameLast Name
Signature
Date

DayMonthYear
Date
Should be Empty: