Liability Insurance Quotation Questionnaire for the Construction & Associated Industries.

The following information that you provide will be assessed by Lloyds’ underwriters &/or brokers’ &/or authorised personal of Platinum Placement Solutions for them to assess the Insured’s insurance risk and provide terms and conditions for a liability quotation for you and your client to consider as appropriate for your clients/their needs.

IMPORTANT

Every proposer or Insured when seeking a new policy of insurance or cover for additional risks or renewal under an existing policy, must disclose any information that might influence the insurers/reinsurers in fixing the premium or determining whether to accept the risk. Failure to do so may entitle insurers to void cover from inception and seek repayment of paid claims. If you are in any doubt as to whether information is material, you should disclose it.
Please read the Disclosure and Non Disclosure notes at the bottom of this questionnaire.

1	Insured:

Name:

Trading As:

Address:

Website:

2	(I) How long has the Insured operated this business?

years

(2) Have you or any director/ partner/manager of the business ever:

(a) had insurance declined or cancelled?	Choose an item..

(b) had an insurer refuse or not invite renewal?	Choose an item..

(c) had any special conditions imposed on a policy of insurance? Choose an item..

(d) had a special excess imposed on a policy of insurance?	Choose an item..

(e) had a claim rejected under a policy of insurance?	Choose an item..

(f) been declared bankrupt or put into receivership or liquidation? Choose an item..

(g) been charged with or convicted of a criminal offence?	Choose an item..

3	Previous Policy Information:

Name of current insurer

(b)	Expiry Date of current policy

(c) Give particulars of any claim made by the Insured during the past five years,

Date	Cost before Excess	Excess	Details

Please attach additional schedule if there is insufficient space.

Is there previous loss history available on current or past underwriters stationary? Choose an item.

If Yes, please include with this questionnaire

(d)	After investigation, are you aware of any circumstances which could give rise to a claim under the proposed Insurance and which are not mentioned above	Choose an item.

If Yes, please supply details

(e) Has the insured been declined liability insurance, or had a liability policy cancelled or a liability policy issued subject to special terms, conditions or restrictions? Choose an item.

If Yes, please supply details

4	Description of construction activities

(a) Please provide full description of the Insured’s current construction activities:

(b) Principal areas of operation within Australia:

(c) Maximum Periods of Contracts entered into

Construction Period	months

Testing & Commissioning weeks

Maintenance Defects months

(d) Contract Value (Single) or Limit any one Contract (Annual):

$

5. Limit of Liability

(a) Public Liability	$ million any one Occurrence

(b) Products Liability $ million in the aggregate any one period of insurance

6	Insured Companies Turnover & Wages

What is the estimated annual turnover?

$

What are the estimated total payments to sub contractors (excluding labour hire payments

$

(c) What are the estimated total payments to labour hire companies

$

(d) What is annual turnover for the expiring year? $

(e) What is annual turnover for the previous 4 years to the expiring year ?

$	$	$	$

2nd last Yr	3rd last Yr	4th last Yr	5th last Yr

(f)	What is the estimated annual:

Salaries $

Wages $

7 Type of work performed

Please indicate the approximate percentage by value of the total work of the Insured according to type:

If NONE state NONE.

Dwellings
1.	Individually Designed	%
2.	Multiple Low Rise	%
3.	Multiple High Rise	%
4.	Modular (i.e. involving repetitive design)	%
Public Buildings
1.	Hospital	%
2.	Schools & Universities	%
3.	Any Other Municipal Buildings	%
4.	Hotels and Recreation Centres	%
5.	Offices
Industrial
1.	Power Plants	%
2.	Chemical, Petro Chemical and Nuclear Installations	%
3.	Manufacturing Plants	%
4.	Industrial Building Systems	%
5.	Mechanical Plant, Bulk Handling Silos	%
Civil Engineering
1.	Highways	%
2.	Bridges, Tunnels and Dams	%
3.	Railways, Harbours and Jetties	%
Airports	%
4.	Sewage / Water Schemes	%
Other
1.	Please Specify-	%
TOTAL	100%

In respect of Residential and Public Buildings

1.	Low rise buildings (up to 3 levels from ground)	%
2.	Mid rise buildings (over 3 levels to 10 levels from ground)	%
3.	High rise buildings (over 10 levels from ground)	%

8	Please state the 5 largest Contracts which have commenced during the past 5 years :

Starting Date	Type of Contract (Building, road, bridge etc.)	Total Contract Value Aust $ Mill	Approx. Completion Date	Were there any Professional Services Provided by the Insured or on behalf of the Insured

9 Professional Duties of the Insured

Are you responsible under contract or agreement for advice design or

specification provided by you?	Choose an item.

Are you responsible under contract or agreement for others advice design or specification that has been provided to you?	Choose an item.

Do you provide advice design or specification solely for a fee	Choose an item.

If yes to any of the above please provide details?

Do you request evidence of Professional Indemnity Insurance from all consultants that provide consultancy services to you?	Choose an item.

Are any of the Directors, Principals or employees, AFTER ENQUIRY, aware of any	circumstances which may give rise to a claim against the Insured Company or any circumstances which may give rise to a claim against you for professional duties?	Choose an item.

If YES, please give details

10	Pollution

Have there been any pollution incidents, complaints, prosecutions, claims or pollution issues?

Choose an item.

If Yes, please provide a brief summary

At the time of this Questionnaire does the proposer know of any facts or circumstances which may reasonably be expected to result in a claim or claims being asserted against your company for environmental clean-up or response or for bodily injury or property damage arising from the release of pollutants into the environment? Choose an item.

If Yes, please provide a brief summary

11 Other business activities

Please describe any other activity of the company that is not related to construction activities/operations.

Turnover applicable-

12	Turnover dissection for Stamp duty calculations

Percentage of 6(a) for current year in each state or territory.

ACT	NSW	NT	QLD	SA	TAS	VIC	WA	Overseas

Confirmation of compliance of duty of disclosure by the insured

Name

Position

Date	Click here to enter a date.

Duty of Disclosure

Before you enter into a contract of general insurance with an Insurer, you have a duty, under the Insurance Contracts Act 1984, to disclose to the Insurer every matter that you know is relevant to the Insurer’s decision whether to accept the risk of insurance and, if so, on what terms.

You have the same duty to disclose those matters to the Insurer before you renew, extend, vary or reinstate a contract of general insurance

Your duty, however, does not require disclosure of matter:

•	that diminishes the risk to be undertaken by the Insurer;

•	that is of common knowledge;

•	that your Insurer knows or, in the ordinary course of business, ought to know;

•	as to which compliance with your duty is waived by the Insurer.

Non-Disclosure

If you fail to comply with your duty of disclosure the Insurer may be entitled to reduce his liability under the contract in respect of a claim or may cancel the contract.

If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning.

About Platinum Placement Solutions

Platinum Placement Solutions Pty Ltd (ABN 68 169 336 252, AR No. 459637) (‘PPS’) is an Authorised Representative of Miramar Underwriting Agency Pty Ltd (ABN 97 111 534 797, AFSL 314176). PPS has a prior submit binder with us under which each risk is agreed by us. PPS has authority on our instructions to issue the Policy to you. In all aspects of arranging this Policy, PPS acts as an agent of the Insurer and not for you.

You can contact PPS by:

Street Address: Level 5, 99 Bathurst Street, Sydney NSW 2001

Phone: 0412 662 262

DUTY DISCLOSURE

Before you enter into an insurance contract, you have a duty to tell us anything that you know, or could reasonably be expected to know, may affect our decision to insure you and on what terms.

You have this duty until we agree to insure you.

You have the same duty before you renew, extend, vary or reinstate an insurance contract. You do not need to tell us anything that:

- reduces the risk we insure you for; or

- is common knowledge; or

we know or should know as an insurer; or

we waive your duty to tell us about.

IF YOU DO NOT TELL US SOMETHING

If you do not tell us anything you are required to, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both.

If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed.

PRIVACY STATEMENT

Please note, only those cover sections shown as covered in your Schedule are insured.

These documents should be read together as they jointly form the contract of insurance between you and us.

We may disclose the personal information we collect to third parties who assist us in providing the above services, such as related entities, distributors, agents, insurers, reinsurers and service providers. Some of these third parties may be located outside of Australia including Philippines, Vietnam, Malaysia and United Kingdom. In all instances where personal information may be disclosed to third parties who may be located overseas, we will take reasonable measures to ensure that the overseas recipient holds and uses your personal information in accordance with the consent provided by you and in accordance with our obligations under the Privacy Act 1988 (Cth).

In dealing with us, you consent to us using and disclosing your personal information as set out in this Privacy Statement. This consent remains valid unless you alter or revoke it by giving written notice to PPS’ Privacy Officer. However, should you choose to withdraw your consent, we may not be able to provide insurance services to you.

PPS’ Privacy Policy which is available at www.platinumplacements.com.au or by calling PPS, sets out how:

PPS protects your personal information;

you may access your personal information;

you may correct your personal information held by us;

you may complain about a breach of the Privacy Act 1988 (Cth) or Australian Privacy Principles and how PPS will deal with such a complaint.

If you would like additional information about privacy or would like to obtain a copy of the Privacy Policy, please contact PPS’ Privacy Officer by:

Postal Address: PO Box A2016, Sydney South NSW 1235

Phone: +61 2 9307 6656

Email: privacyofficer@steadfastagencies.com.au

You can download a copy of PPS’ Privacy Policy by visiting www.platinumplacements.com.au

Producing Brokers Details

Name of Brokerage

Steadfast member	Choose an item.

Brokers Name

Email Address

Phone number

Brokers Signature

Date	Click here to enter a date.