Business Combined Insurance (Liability)

Client Code*

Name of person completing questionnaire*

Insured Name*

Business Combined Insurance

1. Are there any changes in your business activities / operations?*

Yes
No

If YES, please advise full details

2. Have there been any material changes to fire and theft protection alarms, devices and the like during the past 12 months? (e.g. disconnection or dismantling or installation of any services)*

Yes
No

If YES, please advise full details

3. Is there any history of flood damage at the insured location(s)?*

Yes
No

If YES, please advise full details

4. Is there any history of flood damage at any of your key suppliers' premises?*

Yes
No

If YES, please advise full details

5. Is there any history of flood damage at any trade show or exhibition ground where you display goods?*

Yes
No

If YES, please advise full details

Liability

6. Estimated Turnover for the forthcoming year ($)*

7. Number of principals*

8. Number of staff*

9. Estimated Payroll ($)*

10. Are Contractors/Sub-contractors used?*

Yes
No

Activities performed*

Estimated Annual Payments made: $*

Do you sight current Public Liability insurance prior to work commencing?*

Yes
No

11. Are Labour Hire personnel used?*

Yes
No

Activities performed*

Estimated Annual Payments made: $*

Do you sight current Public Liability insurance prior to work commencing?*

Yes
No

12. Any demolition activities*

Yes
No

13. Does demolition exceed 3.5 metres in height?*

Yes
No

if YES, state the maximum height (m) and percentage of turnover (%)

14. Do you Dry Hire? (Hire out plant without an operator)*

Yes
No

15. Do you use, handle or store explosives?*

Yes
No

16. Do you handle, treat remove or transport any asbestos?*

Yes
No

17. Please provide a description of your business activities to ensure your Public Liability cover is sufficient*

Other Insurances

18. Are there any other insurance needs e.g. Insurance of Income, Home, Contents, Motor Vehicle, Caravan, Boat etc, with which we can assist?*

Claims

19. Details of any claims that have occurred, but have not yet been reported*

20. After specific inquiry, details of any facts, circumstances or incidents (other than those already disclosed, notified to your insurer) which could give rise to a future claim*

All changes or inclusions of any sort or type, including limits or sums insured shown, will take effect from the policy's expiry date unless you request otherwise.

Information we have provided to Sarina Insurance Brokers, is to the best of our knowledge correct. Please type your name below:*

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