Complex Risk Liability Proposal Form "*" indicates required fields 1Your Details2Your Business3Your Risk Management Program4Contractors and Subcontractors Details5Pollution Details6Your General History7Your Duty of Disclosure / Non-Disclosure8Declaration CompanyThis field is for validation purposes and should be left unchanged.Please complete all questions fully. If there is insufficient space provided to answer please provide details on your letterhead.Please provide the full legal name of all entities and trading names to be insured under the Policy*(It is important you include all service, administration or nominee companies)Your ABNDate Established:* DD slash MM slash YYYY Business Address:*Telephone or Email:Website:Are any of the Insured and/or its directors listed in any sanctions list generated by Australia, United States of America (US), European Union (EU) and or the United Kingdom.* Yes No Will you be conducting business activities in any sanctioned country listed in any Australian, US, EU and/or UK sanction list.* Yes No Period of Insurance*From 4pm on the Date DD slash MM slash YYYY From 4pm on the Date DD slash MM slash YYYY Limit of Indemnity (any one occurrence and in the aggregate for products liability)*$5,000,000$10,000,000$20,000,000Business Activities* Please provide a full description of your business activities to be insured including applicable turnover $ figure for each activity listed below: Activity 1*Turnover $ AUDActivity 2Turnover $ AUDActivity 3Turnover $ AUDIn 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 quotingNSW %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 Products InformationProducts InformationsPlease provide details of all products for which insurance is required. Please attach product brochures and documents separately*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?* Yes No 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?* Yes No Do you have quality control procedures in place?* Yes No If “Yes”, please provide details of the procedures in place; Your Quality Control & Risk Management ProgramYour Quality Control & Risk Management ProgramHave you obtained ISO 9001 certification for quality assurance?* Yes No Do you ensure all the products you use are compliant with Australian Standards or regulatory requirements for the application it is used for?* Yes No Do you have a standard operating manual or utilise a Safe Work Method Statement (SWMS) or a formal safety document to identify high risk activities, hazards associated and control measures used to manage those risks?* Yes No If “Yes”, please provide details or procedures in place;Do you hold a current license as required by law or industry regulation to undertake the activities in which this insurance will apply to?* Yes No Do you ensure the immediate work area is cordoned off with signage erected to warn of work or activities hazard ahead?* Yes No Do you check to ensure all personnel on site are compliant with Personal Protective Equipment requirements?* Yes No Do you check to ensure all employees and subcontractors engaged have a minimum of 3 years experience and hold relevant qualifications and/or meet statutory requirements to perform the job?* 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?* Yes No This field is hidden when viewing the formContractors and Subcontractors InformationContractors and Subcontractors InformationDo you use contractors or sub-contractors to perform work in your business?* Yes No If "Yes", What are the estimated annual payments and nature of work carried out?Annual PaymentsWork Carried Out Add RemoveDo you use labour hire personnel supplied by labour hire companies in your business?* Yes No If "Yes", What are the estimated annual payments and nature of work carried out?Annual PaymentsWork Carried Out Add RemoveWhat due diligence checks do you undertake to ensure the contractors or subcontractors engaged are suitably qualified and experienced to carry out the work contracted to them?*Please provide details below:Do you hold others harmless or assume the liability of the others regardless of fault under contract?* Yes No If "Yes" please provide details below;Do you ensure that contractors and/or subcontractors have their own liability insurance with a minimum limit of $10,000,000. If Yes, do you check the certificate is current and retain a copy for your records each time?* Yes No Do you ensure all contractors and/or subcontractors are inducted for WHS on site prior to commencement of work?* Yes No This field is hidden when viewing the formPollution DetailsPollution DetailsDo any of your trade processes produce toxic waste or pollutants which have the potential to injure people or damage property or otherwise harm the environment?* Yes No If “Yes” please provide full details including quantities & how hey are stored/handled:Do you dispose all waste lawfully?* Yes No Are you required to hold licenses with the EPA, Work Cover, or any other regulatory authority?* Yes No If "Yes", please provide full details: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 Yes No If “Yes”, please provide exact nature of work carried below at the above premisesIf you have insufficient space to complete your answers, please attach detailed information on a separate sheet This field is hidden when viewing the formYour General HistoryYour 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?* Yes No of any liability claims made against you?* Yes No of any of your products being recalled?* Yes No of an incident or accident which would be insured by this proposed insurance?* Yes No anyone having been charged with or convicted of any criminal offence (excluding traffic offences)?* Yes No If you or the company ever been fined or prosecuted for any workplace work, health or safety breaches of any kind?* Yes No 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)?* Yes No Your Duty of Disclosure / Non-DisclosureYour Duty of Disclosure / Non-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. DeclarationDeclarationI 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. Untitled I have read and agree to the duty of disclosure requirements. Declaration signature(s) on behalf of the applicants:Signature*Print Name:* First Last Phone NumberDate* DD slash MM slash YYYY Your Email Address (to receive a copy of this proposal)* Δ