Public Liability Insurance Needs Analysis
Broker Email Address - a copy of the form will be sent to this address
*
example@example.com
Client Reference
*
Date of Enquiry
-
Day
-
Month
Year
Date
Policy Due Date
-
Day
-
Month
Year
Date
Current Insurer
Who referred client?
Sales Team
Insured Details
Insured Name
Client Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: 0000000000.
Business Name
No. of years business established
Website
Turnover
$
Wages
$
No. of Staff/Directors
No. of Subcontractors
Subcontractors Turnover or %
$%
Subcontractors
Occupation
Experience in Years
Full description of activities
Hoists/Cranes
Please Select
Yes
No
If yes, please provide
Number
Use
Unregistered Vehicles
Please Select
Yes
No
If yes, please provide
Number
Use
Importing/Exporting
Please Select
Yes
No
Details
Other Extensions
Insurance History
Has the Insured ever had insurance cancelled, declined or special conditions imposed?
Please Select
Yes
No
Has the Insured ever been charged or convicted of any criminal offence?
Please Select
Yes
No
Has the insured ever been declared bankrupt or been placed in receivership?
Please Select
Yes
No
If yes, please provide full details
Claims History
For last 5 Years
Claim #1
Insurer
Details of Claim
Amount
$
Claim #2
Insurer
Details of Claim
Amount
$
Claim #3
Insurer
Details of Claim
Amount
$
Details of Cover
Rows
Limit of Liability $
Current Excess $
Quoted Excess $
Public Liability
Products Liability
Goods in car, custody & control
Property Owners
Other endorsement/extensions
Broker Recommendations
Print Form
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Submit
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