Combined General & Products Liability Insurance

Client Code*

Name of person completing questionnaire*

Insured Name*

1. Any changes in your business activities / operations?*

Yes
No

2. Estimated Turnover for the forthcoming year: $*

3. Number of Principals:*

4. Number of Staff:*

5. Estimated Payroll*

6. 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

7. 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

8. Any demolition activities*

Yes
No

9. Does demolition exceed 3.5 metres in height?*

Yes
No

State maximum height*

Percentage of turnover*

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

Yes
No

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

Yes
No

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

Yes
No

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

Claims

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

15. 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 is to the best of our knowledge correct.

Name

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Combined General & Products Liability Insurance

Claims

Sarina Insurance

General Info

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