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)
     - -
  • Period of cover Required (To)
     - -
  • Expiry date of current insurance
     - -
  • Limit of Liability Required*
  • Optional Excess*

  • Company Information

  • On What Date Was the Company First Established/Commenced Trading?
     - -

  • Operational Information

  • Are all Directors, Employees, and Sub-Contractors Licensed Scaffolders?*
  • Is work carried out over 10 metres?*
  • Do you perform work on, at, or from any of the following sites:*
  • Do you manufacture any scaffolding products?*
  • Do you regularly hire out scaffolding for long-term contracts?*
  • Do you regularly inspect the above equipment for safety and maintenance?*
  • Do you have documentation to support repair, maintenance and safety inspections in place for all of your equipment?*
  • Do you sell any used or second-hand equipment?*
  • Do you have formal training in place for your staff?*
  • Do you own or hire lifting equipment for the erection of scaffolding?*
  • Does your product or service comply with the relevant Australian Standards?*
  • Do you assume or provide liability under contract or hold harmless agreements?*
  • Will you adopt the ASR Incident Reporting Procedures?*

  • Turnover/Income Details

  • Rows
  • Are contractors/sub-contractors required to carry their own insurance for public liability?*
  • Are contractors/sub-contractors required to carry their own insurance for workers compensation?*
  • Rows
  • Rows

  • History

    Important: If you are in any doubt refer to your broker to ensure all relevant details are disclosed
  • Have you ever had any fine or penalty or infringement notice violations issued against you?*
  • Have you or any persons connected with this insurance ever had a revoked licence?*
  • Have you or any partner or director been declared bankrupt, had legal proceedings lodged against you or been convicted of any criminal offences? If yes, please provide details below.*
  • Have you or any partner or director had an insurer that has declined to renew or imposed special conditions?*
  • Have you within the last 10 years, suffered a claim that would have been covered by this insurance and or claimed for any loss or damage or received any demand or writ for personal injury or damage to property?*
  • After enquiry, are you or any director or employee aware of or have grounds for suspecting any circumstances, which might give, rise to a claim, against you or against any of the present or former directors during the last 10 years?*
  • Have you or anyone in your employ every been charged with any breaches of the relevant Occupational and or Workplace and Safety Acts in respect of your business?*

  • Declaration

    Your Duty of Disclosure
  • I confirm that:*
  • Date Signed
     - -

  • 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.

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