Liability Proposal Form Download PDF Form General InformationAll entities to be insured in this application(Required)Premises occupied to conduct your business:(Required)Period of InsuranceFrom 4pm on the Date(Required) DD slash MM slash YYYY From 4pm on the Date DD slash MM slash YYYY Public Limit of Indemnity any one occurrence(Required)Products limit in the aggregate for Period of InsuranceYears in continuous operation:(Required)Your website:Details of your business activitiesTurnover in past 12 months AUD :Estimated turnover coming 12 months AUD(Required)Please list full description of your business activities including applicable turnover % for each activity listed below: Activity 1(Required)% of Turnover(Required)Activity 2% of TurnoverActivity 3% of TurnoverIn respect of turnover for the last financial year, please provide a % breakdown by state:Please forward completed exemption form for NSW eligible companies for stamp duty component to be removed at quoting(Required)NSW %ACT %QLD %VIC %TAS %SA %WA %NT %Overseas %Total % Add RemovePlease forward completed exemption form for NSW eligible companies for stamp duty component to be removed at quoting Employee InformationTypeWages/SalariesStaff numbers Add Remove Add Remove Add Remove Add RemovePlease provide details of any of the following:Boiler/pressure vessels:Do you hire out equipment? Yes No Do you hire out equipment with an operator? Yes No Is there a Hire Agreement with a disclaimer or legal waiver in place that the hirer signs before hiring? Yes No Is all equipment checked and maintained after each hire? Yes No Unregistered vehicles/ hire out equipment? (Number and type of type of equipment):Products InformationPlease provide details of all products for which insurance is required. Please attach product brochures and documents separately(Required)Product Name or TypeFunction / End useManufactured (M), Imported (I), Distributed (D) and Exported (E).Turnover/ SalesOrigin / Destination Add RemoveDo you modify, re-label or repackage any of the products you import, export or distribute?(Required) Yes No If "Yes" can you please provide details below on the type of work carried out.Are any of your products used in motor vehicles, aircraft, watercraft, hovercraft, rail equipment, at power stations or chemical plants or mining or drilling sites?(Required) Yes No If “Yes” please provide full details below.Do you manufacture any petrochemicals, industrial chemicals, pesticides, fungicides, fertilisers or radioactive materials?(Required) Yes No If “Yes” please provide full details below.Do you export any of your products to North America, For the purpose of this insurance, North America is defined as the United States of America and Canada and its dominions and protectorates.(Required) Yes No If Yes, please specific product type and its end use applicationCan you please disclose % of turnover related to exportsOr AUD $Do you own or operate a Limited Liability Company (LLC) entity or subsidiary in the United States of America and Canada and its dominions and protectorates.(Required) Yes No If “Yes”, we are not able to cover these entities and local cover will need to be sourced overseas.Quality Assurance & Risk Management ControlsDo you have quality control procedures in place?(Required) Yes No If “Yes”, please provide details or procedures in place;If you are involved in the importation of goods or products, do you ensure all products are third party tested to ensure compliance with Australian Standards or quality warranty as required by law?(Required) Yes No If “No”, please clarify how you check for quality or if its fit for purpose.Have you obtained ISO9001 certification?(Required) Yes No Date Accredited / Certificate No:Are all goods or products manufactured compliant to Australian Standards (If applicable)?(Required) Yes No If “No” please clarify how you check for product quality or ensure it complies with regulatory requirements for its end use application.Do you ensure all products labels include clear instructions on use and contain health and safety warnings?(Required) Yes No If “No” how to you ensure you have discharged your duty of care to the end customer in regards to product safety.For all the product which you manufacture, can you with certainty identify the source of each item or all raw materials used ?.(Required) Yes No Is there a dedicated person in your company or management that is responsible for overall safety including cleanliness of site, factory and enforcing occupational health and safety risk controls in your workplace on each shift?(Required) Yes No Please provide details belowContractors and Subcontractors InformationDo you use contractors and/or sub-contractors to perform work in your business?(Required) Yes No If "Yes", do they work under your direct supervision or control?(Required) Yes No What are the estimate annual payments?What are the nature of work they carry out?Are they require to carry their own insurance for:a.) Public Liability Yes No Minimum Limitb.) Workers Compensation Yes No How this is checked?Do you use labour hire personnel supplied by labour hire companies in your business?(Required) Yes No ListCompanyType of workAnnual payments Add RemoveAre you required to insure these personnel for Workers Compensation?(Required) Yes No Do you hire out your employees to third parties on a labour hire basis?(Required) Yes No If "Yes", what is the estimated annual turnover received?What is the type of work they perform?(Required)Do you assume the liability of others under contract or hold others harmless?(Required) Yes No If "Yes", please provide details and attach copies of agreementsFileMax. file size: 128 MB.Coverage for liability will be limited to incidental contracts and or liability which would have been imposed by law in the absence of such contract or agreement i.e. electricity, fuel, gas, air, water, sewerage, waste disposal, telephone and communication services. Do you ensure that contractors and/or subcontractors have their own liability of $10,000,000(Required) Yes No If "Yes" to the above, please provide details of work performed by the contractors and subcontractors in your business or on your behalf. Please provide any payments made in the "Other" section of the payroll information.Do you check the insurance is current and retain a copy for your records each time(Required) Yes No Do you ensure all contractors and/or subcontractors are inducted for WHS on site prior to commencement of work(Required) Yes No Work away from premisesDo you conduct any activity on, or work away from premises at or on or in; a) the operation, service or repair of airports and aerodromes including air traffic control equipment, runway, taxiway, runway threshold, apron, hanger, aircraft stand and fuel farm of any kind b) the service, repair, maintenance and operation of trains, trams, rolling stock and light rail services including the signals and overhead electrification system of any kind c) any inspection, repair and service on offshore oil and gas platforms, floating production storage and offloading (FPSO) and drilling rigs or related equipment of any kind d) underground work on mine shafts and tunnels of any kind e) any subaqueous or underwater work of any kind f) any construction, maintenance and repair of dams, reservoirs or weirs impacting the structure of the dam of any kind g) petrochemical plants, refineries, tank farms, fuel depots and storage facilities, oil and gas pipelines including its related infrastructure for above/below ground and undersea uses h) power stations including service, maintenance and repair on turbines, generators, boilers, conveyor systems, cooling tower, substations and transmission lines of any kind i) the blasting or use of explosive or detonation devices of any kind j) the demolition of buildings or other structures exceeding 5 metres in height of any kind k) operation of thermal coal-fired power plants, thermal coal mines, oil sands, or new Arctic energy exploration activities of any kind l) the operation of any toxic waste disposal facility, waste transfer station and landfill site of any kind m) the use fireworks, ammunition, fuse, cartridges powder, Nitroglycerin and or any substances intended for use as an explosive of any kind n) the service, repair, maintenance, and operation of commercial vessel of any kind. For the purpose of this exclusion a commercial vessel is defined as a ship used for activities that are undertaken for financial reward or fee Work away from premises(Required) Yes No If “Yes”, please provide details belowIf you have insufficient space to complete your answers, please attach detailed information on a separate sheetYour General History1. After investigation, are you or any principal, partner, or director aware:of any insurance being declined or cancelled, application/proposal rejected, renewal refused, Yes No claim rejected, or special conditions or excess imposed by any insurer?(Required) Yes No of any liability claims made against you?(Required) Yes No of any of your products being recalled?(Required) Yes No of an incident or accident which would be insured by this proposed insurance?(Required) Yes No anyone having been charged with or convicted of any criminal offence (excluding traffic offences)?(Required) Yes No If you or the company ever been fined or prosecuted for any workplace work, health or safety breaches of any kind?(Required) Yes No If ‘Yes” to any of the above, please provide details below:(Required)2. Have you ever, either alone or jointly with others been declared bankrupt or subject to any form of insolvency administration (eg. liquidation or receivership)?(Required) Yes No If ‘Yes”, please provide details below:(Required)Your Duty of DisclosureFor the avoidance of doubt, You, Your, Me, My, I means any principal, director, stockholder or shareholder, partner, proprietor, officer, executive, or employee authorised to complete this insurance application on behalf of all entities to be insured in this application Us, We, Our is defined as Ocean Underwriting Pty Ltd acting under a binder as an agent of the insurer Before You enter into a contract of insurance with Us, You have a duty under the Insurance Contracts Act 1984 (Cth) to disclose to Us anything that You could reasonably be expected to know is relevant to Our decision whether to accept the risk of insurance and if so, on what terms. You have the same duty to disclose those matters to Us before You renew, extend, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of a matter: • that diminishes the risk to be undertaken by Us; • that is of common knowledge; • that We know or, in the ordinary course of business, ought to know; or • as to which compliance with Your duty is waived by Us. The duty of disclosure applies to You and everyone insured under the contract of insurance. If You, or they, fail to comply with the duty of disclosure, We may reduce Our liability under the contract in respect of a claim. If the non-disclosure is fraudulent, We may treat the policy as if it never existed and pay nothing. It is important that all information provided in support of Your application for insurance is understood by You and is correct, as You will be bound by Your answers and by the information provided by You. If You do not understand any part of this notice, You should obtain independent advice. Your duty of disclosure continues after Your application for insurance has been completed up until the contract of insurance is entered into Non-DisclosureIf You: (i) failed to disclose any matter which You were under a duty to disclose to the Us, or (ii) made a misrepresentation to the Us before this policy was entered into and if We would not have entered into this policy for the same premium and on the same terms and conditions expressed in this Policy but for the failure to disclose or the misrepresentation then - (a) Our liability in respect of any claim will be reduced to an amount to place Us in the same position in which We would have been placed if such non-disclosure had not occurred or such misrepresentation had not been made; or (b) if the non-disclosure or misrepresentation was fraudulent, We may avoid this policy. DeclarationI declare that to the best of my/our knowledge and belief the answers given above, documents or papers submitted, represent the true position and that We have not withheld any information, material to this proposal. I acknowledge that no cover is provided unless and until; Ocean Underwriting advise in writing of the cover and terms which they can provide, and this cover including the terms and conditions is then accepted by me, and Ocean Underwriting are advised by me of acceptance of their cover and terms offered, and Ocean Underwriting acknowledges to me that cover is provided. Where answers in this proposal are not in my own handwriting, they have been checked by me and I agree that they are correct. I have read and understood the Your Duty of Disclosure notice in this proposal form. I authorise Ocean Underwriting to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to or which may impact on this insurance cover, and any other insurances held by Me and claims under those insurances. I agree that this proposal and accompanying documents or papers shall form part of this proposal and are the basis of the insurance contract proposed. I have read and agree to the duty of disclosure requirements.(Required) I have read and agree to the duty of disclosure requirements. Declaration signature(s) on behalf of the applicants:Signature(Required)Print Name:(Required) First Last Phone Number(Required)Date:(Required) DD slash MM slash YYYY Your Email Address (to receive a copy of this proposal)(Required) Δ