Personal DetailsFirst Name(Required)Last Name(Required)Occupation(Required)ABN(Required)Entity/Company Name(Required)Email(Required) Phone Number(Required)Street Address(Required)Suburb(Required)State(Required)Post Code(Required)Insurance CoverPublic and Product Liability Limit(Required) $5 000 000 $10 000 000 $20 000 000 more then $20 000 000 Number of Direct Employees(Required)Estimated Annual Turnover (in dollars)(Required)Do you engage contractors/subcontractors?(Required) Yes No Estimated Payment to Subcontractors (in dollars)(Required)General Information and DisclosureSelect if you conduct work at or in connection with:(Required) None of the below Mine sites Elevators Escalators Travelators Tower Cranes or Derrick Cranes Asbestos Removal Medical/Hospital Facilities High voltage power lines Operate the business outside of Australia Public Utilities Bridges or dams Use of the explosives Handle hazardous substances Ship or Marine Risk Do you engage in any of the following activities?(Required) None of the below Working on heights over 10 meter Work under 3 meters in depth Commercial work Driving Risk Designed contracts and Hold Harmless agreements Perform hot works away from premises Hire out equipment or staff Select if you or any partner(s) or director(s) of the business have(Required) None of the below Insurance policy cancelled or declined Ever been declared bankrupt Been insolvent or in voluntary administration Been convicted of any criminal offence Been liable for any civil offence or pecuniary penalty Special Conditions Imposed on the policy Have you had any Public Liability claims in the last 5 years? If yes to any of the above questions please provide full details belowOther Relevant Information you wish to disclose
