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General & Products Liability Security Proposal Form
GENERAL & PRODUCTS LIABILITY SECURITY PROPOSAL FORM
Url
ACCEPTANCE OF PROPOSAL
I have read and understood the Important Notices
*
Yes
No
APPLICANT DETAILS
Insured and trading Name (incl. all subsidiary companies)
ABN
Taxable (GST input %)
Address
Suburb
State
ACT
NSW
NT
SA
TAS
VIC
WA
OS
Postcode
Business Number
Current Insurer
Mobile Number
Expiry Date of Current Policy
Email Address
Business Operating Hours
Website
Year Business Started Operating
Name of Partners/Directors
Name
Name
Qualifications/Experience
Qualifications/Experience
Name
Name
Qualifications/Experience
Qualifications/Experience
COVERS REQUIRED
Period of insurance
From
To
Limit of Liability ($)
UNDERWRITING INFORMATION
Describe your Business Activities
Do you sell or distribute and products?
Yes
No
Total Expiring Turnover ($)
Total Expiring Wages
Total Estimated Turnover for the coming period of insurance
Total Estimated Wages for the coming period of insurance
For the purpose of Stamp Duty, please provide a breakdown by State of the Turnover for the last Financial year
ACT
NSW
VIC
QLD
TAS
SA
WA
NT
OS
Total
%
This must total 100%
Number of Full Time Staff
Number of Part Time Staff
CONTRACTORS AND/OR SUB-CONTRACTORS
Do you use sub-contractors?
Yes
No
Do you utilise the services of a Labour Hire Firm?
Yes
No
Do you assume liability under contract or hold others harmless (other than lease liability)?
Yes
No
PERCENTAGE OF TURNOVER DERIVERED FROM EACH OF THE FOLLOWING ACTIVITIES
Design or alteration of Security Systems
Security System Consultants
Alarm Monitoring
Body Guarding
Traffic Controlers
Use of Firearms
Crowd Control
(Crowd control addendum required)
Installation of Security Systems
Manufacturing of Security Systems
Alarm Response
Debt Collecting
Security Training
Use of Dogs
Sales, Servicing & Maintenance of Security Systems
Static Guarding - e.g. business premises, shopping centres, banks, etc.
Mobile Patrols
Cash Carry
Education Programs
Guard Dog traning and/or breeding and/or sale of dogs
Other Activities
Type of activities
Percentage
Type of activities
Percentage
Total
%
This must total 100%
DETAILS OF ACTIVITIES
STATIC GUARDING & MOBILE PATROL
Please describe the type of premises You are providing Static Guarding & Mobile Patrol operation for. (Example - Office, Retail, Shopping Centres, Construction, Industrial Warehousing, Council)
Do You provide Static Guarding to Shopping Centres?
Yes
No
Is the work conducted during both day and night?
Yes
No
Does the contract stipulate crowd control for the shopping centres as well as Static Guarding/Mobile Patrols or only Static Guarding?
Yes
No
Are You responsible for any cleaning activities?
Yes
No
Do You have contracts in place?
Yes
No
Are You providing work at hotels?
Yes
No
Are You providing any type of quarantining work?
Yes
No
GUARD DOGS
Do you require insurance cover for guard dog activities?
Yes
No
FIREARMS
Do you require insurance for the use of firearms?
Yes
No
CASH IN TRANSIT
Do you require Cash in Transit insurance?
Yes
No
CRIMINAL DEFENCE COST
Do you require insurance cover for Criminal Defence Expenses.
Yes
No
Note: Sum insured shall not exceed $50,000 in the aggregate any one Period of Insurance.
STATUTORY LIABILITY
Do you require insurance cover for Statutory Liability?
Yes
No
DETAIL OF ACTIVITIES (continued)
CASH IN SAFE
Do you require Cash in Safe insurance?
Yes
No
PROFESSIONAL INDEMNITY
Do you require insurance cover for Professional Indemnity?
Yes
No
RISK MANAGEMENT
Do you have suitable first aid equipment?
Yes
No
Do you keep and maintain an incident report procedure and log?
Yes
No
Do you comply with all relevant Australian/New Zealand Standards and legislation that pertain to your business?
Yes
No
Are you a member or accredited with any association?
Yes
No
Do you have the appropriate current accreditation in Risk Management and Occupational Health and Safety?
Yes
No
CLAIMS AND GENERAL HISTORY
Have you, your partners, any other office-holders, or if a corporation, any of its directors proposed to be insured under this policy, either alone or jointly:
a) been convicted of or changed with any civil or criminal offence?
Yes
No
b) ever been declared bankrupt?
Yes
No
c) ever had insurance refused or cancelled or has any insurer ever imposed special terms, conditions or restrictions on your policies?
Yes
No
Are you aware of any uninsured losses or unreported incidents that may give rise to a claim?
Yes
No
If Yes to any of the above questions, please provide details
Detail all insurance claims made in the last 5 years
Date
Date
Date
Amount
Amount
Amount
Description of Loss
Description of Loss
Description of Loss
Crowd Control Addendum
CROWD CONTROL TURNOVER SPLIT
Type of Venue
Type of Activity
% of Crowd Control Turnover
Permanent Stadiums
Temporary Stadiums
Private functions at Licensed Venues
Private functions at Unlicensed Venues
Community Events
Licensed Venues
Licensed Venues
Licensed Venues
Licensed Venues
Licensed Venues
Permanent Stadiums
Temporary Stadiums
Private functions at Licensed Venues
Private functions at Unlicensed Venues
Community Events
Licensed Venues
Licensed Venues
Licensed Venues
Licensed Venues
Licensed Venues
%
*
0
%
0
%
0
%
0
%
0
%
0
%
0
%
0
%
0
%
0
Total Percentage
%
Must total 100%
Crowd Control Addendum (continued)
Please provide the following details for your 10 largest Crowd Control Security Contracts
Venue Name
Suburb & State
Type of Venue (refer to previous page)
Average Attendees
Average Number of Security Staff Supplied
Do you regularly use sub-contracted Security?
Number of days per year you provide security staff for this venue
How long has contract been held?
Venue Name 1
Suburb & State
Type of Venue
Attendees
Staff
Sub-contract
Y
N
Days
How Long
Venue Name 2
Suburb & State
Type of Venue
Attendees
Staff
Sub-contract
Y
N
Days
How Long
Venue Name 3
Suburb & State
Type of Venue
Attendees
Staff
Sub-contract
Y
N
Days
How Long
Venue Name 4
Suburb & State
Type of Venue
Attendees
Staff
Sub-contract
Y
N
Days
How Long
Venue Name 5
Suburb & State
Type of Venue
Attendees
Staff
Sub-contract
Y
N
Days
How Long
Venue Name 6
Suburb & State
Type of Venue
Attendees
Staff
Sub-contract
Y
N
Days
How Long
Venue Name 7
Suburb & State
Type of Venue
Attendees
Staff
Sub-contract
Y
N
Days
How Long
Venue Name 8
Suburb & State
Type of Venue
Attendees
Staff
Sub-contract
Y
N
Days
How Long
Venue Name 9
Suburb & State
Type of Venue
Attendees
Staff
Sub-contract
Y
N
Days
How Long
Venue Name 10
Suburb & State
Type of Venue
Attendees
Staff
Sub-contract
Y
N
Days
How Long
DECLARATION
By submitting this form, I hereby declare that:
• I have read and understood the Important Notices set out in the Proposal. • I am authorised to complete and sign this declaration on behalf of all the applicants. • I confirm that the answers and statements in this Proposal are true and correct and I have not withheld any information which my affect the decision to accept this Proposal or the items and conditions of any insurance provided. • I understand that if this Proposal is accepted, the insurance cover will be subject to the terms and conditions set out in the Policy. • I acknowledge that the particulars and statements contained in this Proposal shall form the basis of the contract should a Policy be issued. • I further acknowledge that EUS on behalf of the Insurer may decline this Proposal. • I consent to EUS/the Insurer using the personal information (including sensitive information) I have provided on this Proposal form and any attachments for the purposes of administrating this insurance. I consent to the disclosure of personal information (including sensitive information) to third parties and overseas where it is reasonably necessary for the purposes of administrating this insurance. Where I have provided personal information on behalf of another person I have complied with my obligations as set out in the Privacy Statement. • I understand that this insurance does not operate until EUS issues the Policy Schedule and the premium has been paid (except for any cover provide under an interim contract of insurance).
