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Certificate of Currency
Claim
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Public Liability
Liability Form
Insured Name
ABN
Email
Phone Number
Director(s) Name(s)
Business Description (What do you do?)
Insured Address
Address Line 1
Address Line 2
City
State
Area Code
The Gross Turnover Last Financial Year in Australia
The Gross Turnover Current Financial Year in Australia
The Gross Turnover Coming Financial Year in Australia
Confirm which State/Territory You Operate In
NSW
VIC
QLD
SA
WA
TAS
NT
ACT
Do you Operate Overseas?
- Select -
Yes
No
Do you work at any of the following:
None
Drag Line Excavators
Highvoltage Power Supply Areas
Airport Tarmacs and Aircraft Hangars
Wharves and Ship Handling Facilities
Underground Mines
Railway Tracks and Related Infrastructure
Steelworks
Do you work over 10m in height?
- Select -
Yes
No
Do you dig more than 2m in depth?
- Select -
Yes
No
Confirm That You Will Always Contact Dial Before You Dig or A Similar Service
- Select -
Confirm
Do Not Confirm
Do You Operate Unregistered Plant?
- Select -
Yes
No
Do You Handle Dangerous Goods?
- Select -
Yes
No
Do You Handle Asbestos?
- Select -
Yes
No
Do you Perform any Welding?
- Select -
Yes
No
Do you Import or Export?
- Select -
Yes
No
Do you assume liability or contract in additional exposure?
- Select -
Yes
No
Do all subcontractors carry their own Public & Products Liability insurance?
- Select -
Yes
No
Number of Full Time Employees
Number of Part Time or Casual Employees
Do You Comply with Safety Legislation?
- Select -
Yes
No
What Are Your Risk Management Procedures?
Do You Hire In Any Assets?
- Select -
Yes
No
PUBLIC LIABILITY - Limit of Liability
- Select -
$5,000,000
$10,000,000
$20,000,000
$50,000,000
PRODUCTS LIABILITY - Limit of Liability
- Select -
$5,000,000
$10,000,000
$20,000,000
$50,000,000
PRODUCTS LIABILITY - Care, Custody and Control
- Select -
$250,000
$500,000
$1,000,000
Is Accident & Sickness Required?
Yes
No
Previous Claims Declined?
- Select -
Yes
No
Ever been liable for any civil offence or pecuniary penalty?
- Select -
Yes
No
Ever been charged or convicted of a criminal offence?
- Select -
Yes
No
Ever had an insurance policy cancelled, declined or terms imposed?
- Select -
Yes
No
Aware of circumstances which could give rise to a claim?
- Select -
Yes
No
Anything to Declare under Duty of Disclosure?
- Select -
Yes
No
Additional Information about you or the property
Submit Form
