Step 1 of 11 - Personal Details 9% Can I start with your personal Details?HiddenGeneral DetailsType of Proposal*Please select and option belowThis is a renewalI would like a quote, I am insured elsewhereI would like a quote, this is a new ventureContact name* First Last Email address* Phone number* Nice to meet you! Please tell about your BusinessHiddenBusiness DetailsLegal Entity Trading name* ABN* Website Street AddressAddress* Number Street Suburb State Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Postal AddressPostal Address* Same as above Different address HiddenPostal AddressPostal Address* Number Street Suburb State Postcode Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands HiddenYear Business Established Great! Tell about your Business TurnoverHiddenBusiness TurnoverEstimated Turnover for the next 12 monthsActual turnover last 12 monthsTurnover Split by StateNSWVICQLDWASANTACTTASTotalMust equal 100%Consent Tick if you are a small business eligible for the exemption from the requirement to pay NSW duty on certain types of insurance?Note, a small business under the changes relating to the NSW Stamp Duty exemption defines that a business is a small business for an income year (the current year) if: You carry on a business in the current year; and One or both of the following applies: You carried on a business in the income year (the previous year) before the current year and the aggregated turnover for the previous year was less than $2m; The aggregated turnover for the current year is likely to be less than $2m. For more information, visit: https://www.revenue.nsw.gov.au/taxes-duties-levies-royalties/insurance-duty/exemptions Please list about Insurance DetailsHiddenInsurance DetailsPublic Liability $5,000,000 $10,000,000 $20,000,000 $50,000,000 Nil Professional Indemnity $100,000 $500,000 $1,000,000 $2,000,000 $5,000,000 $10,000,000 Nil Period of InsuranceFromToRetroactive DateProfessional Indemnity & Public Liability Well! Now list all your ActivitiesActivities Pest Control Termite Management Timber Pest Building Inspection Other Pest ControlPercentage of Turnover Urban Pest Management Agricultural Pest & Weed Control Trapping and Relocation Fumigation (AS2476) Pest Proofing Feral Animal Control Cotton Spraying Firearm or Explosive Use HiddenSection Break - Agricultural Pest & Weed Control / Cotton SprayingGeographical area of operationDoes the proposer undertake any tree lopping?How many years’ experience does the proposer have with Agricultural Pest & Weed Control / Cotton Spraying?Specific details of pests and weeds controlled by the Insured (incl crop type, and % of work this represents)Details of chemicals used by the proposer, including source of acquisitionDetails of weather checking / record system in use (electronic, manual)Details of weather checking / record system in use (electronic, manual)Details of systems in place for correct identification of crop location / job areaWhat is the equipment, including towing or carrying, is used by the insuredHow is the equipment cleaned after use and / or when chemicals are changed?HiddenSection Break - FumigationIf the proposer undertakes fumigation of imported goods, please advise type(s) of fumigation performed, who performs the work, Who checks / signs-off on the treatment?HiddenSection Break- Firearm or Explosive UseIf “Yes”, please confirm whether you comply with all statutory obligations, by-laws and/or regulations imposed by any relevant authorities for the ownership, use and/or storage of firearms and explosive devices and/or stored in connection with your business activities only? Yes No Termite ManagementPercentage of Turnover Termite Management - new construction (AS 3660.1) Termite Management including inspections - existing buildings and structures (AS 3660.2) Timber PestPlease note that you are required to have CPPUPM3008 (Unit 8) Inspect for and report on timber pests and CPPPUM3010 (Unit 10) Control timber pests to conduct Timber Pest Inspections.Percentage of Turnover Timber Pest Inspections (AS4349.3) Building InspectionPercentage of Turnover Pre-Purchase Building Inspection (AS4349.1). Pre-Sale Inspections Stage Inspections Handover Inspections Mandatory Inspections (max 3 stories, 1 basement) Special Purpose Building Inspections Dilapidation Inspections Owner Builder Defect Inspections Insurance Investigation Depreciation Schedules Strata Sinking Fund Inspections Mould Identification Inspections Asbestos Inspection (visual only) Asbestos Inspection (sampling) Methamphetamine Detection (Methamphetamine Detection) Dispute Resolution, Mediation & Expert Witness Please note this policy does not cover Swimming Pool Barrier, Fence Safety Inspecting and Certifying. Mandatory inspections limited to a maximum 3 stories and 1 basement level.OtherPercentage of Turnover Carpet Cleaning Cleaning Disinfecting & Sanitising Services Handyman (non-structural) Hygiene Services Lawnmowing Other activities not notedHiddenSection BreakTotalMust equal 100% Please provide a breakdown of turnover split by the following locations.HiddenBreakdown Turnover split by locationDomestic / ResidentialCommercialIndustrialAgriculturalFish FarmsChicken FarmsGolf CoursesWorked performed under power linesTotalMust equal 100%Any work undertaken at fish farms, chicken farms, golf courses or under powerlines?* Yes No If yes please provide details of the nature of work and frequency.Is there any work undertaken at food manufacturing, grain silos, cool rooms, grain handling and other food preparations facilities?* Yes No If yes, please confirm where you conduct your activities and what safety precautions are undertaken?Is there any work undertaken adjacent to any water course, dam, tailing dam and/or river?* Yes No If Yes, what safety precautions are undertaken?Is there work undertaken refineries, chemical plant, petrol, oil or gas production facilities, offshore platforms/oil rigs, utilities, oil or gas pipelines, power stations, laboratories, water treatment plants, railway infrastructure, airports, underground work, dams, work on trains, watercraft or aircraft?* Yes No If Yes, what safety precautions are undertaken?Does the proposer have representation outside Australia?* Yes No If Yes, where and what is the nature of your representation in such country (e.g. domicile employee power of attorney, branch, subsidiary, agency etc.)Do the proposer import or manufacture pest control products?* Yes No If you please advise, who manufactures the products, the testing regime in place in respect of the product, advise of any independent testing conducted by a third party and are the products solely for your use or do you sell to other parties?Does the Applicant undertake tree surgery, tree looping or clearing?* Yes No It Yes, please note the locations (i.e urban, rural) and if it is over or under 3 meters in height? List number of your Employees working in Part-time or Full-time.HiddenEmployee Numbers (including yourself)Office / Admin StaffFull-timePart-timeTechnicians / Inspectors / OperatorsFull-timePart-timeEnter Licence & Qualifications (including firearms).HiddenEmployee Licence & QualificationsQualifications, Licence and Number of Years Experience Name Qualifications Licence Number Building Inspections Timber Pest Inspections General Pest Management Actions Edit Delete There are no Entries. Add Details Maximum number of entries reached. HiddenSub Contractor & Labour HireTell about your Sub Contractors & Labour HireDoes the proposer engage the use of subcontractors?* Yes No Does the proposer engage the use labour hire personnel?* Yes No If yes, please provide the following informationEstimated annual paymentsDose the proposer enter into a written agreement with the subcontractor or labour hire company?* Yes No Does the proposer request evidence of professional indemnity, public liability, and workers compensation insurance?* Yes No More about Risk ManagementHiddenRisk ManagementDo all principals, directors, employees and trainees hold current relevant licences or certification to conduct the activities noted by you?* Yes No Does the proposer comply with the following in relation to the activities noted and undertaken by any person engaged by you?* 1. Australia Standards 2. Industry Code of Practice 3. Statutory Regulations Yes No Confirm the proposer only mixes or formulates chemicals as per manufacturer’s instructions or specifications.* Yes No Are the proposer’s terms and conditions provided by a third party (i.e. Report Systems Australia)?* Yes No If yes which third party, if not have they been vetted by a legal practitioner?*What software does the proposer use? If you answered No to any of the questions in the Risk Management section, please provide details below: Provide your Claim History - Professional Indemnity and LiabilityHiddenClaim HistoryHas the Applicant including directors, officers, employees had any cliams made against you (whether insured or not) or have you recalled any of your products during the last 10 years?* Yes No Has the applicant, including all directors, officers, employees ever been subject to disciplinary proceedings for professional misconduct?* Yes No Have any claims for negligence, professional negligence or breach of professional duty been made in the last 10 years against any applicant or any of their predecessors in business or any prior business of any of their present or former directors, partners, principles or employees?* Yes No Do any circumstances exist that might give rise to a claim against an applicant or any director, officer, employee or agent for negligence, professional negligence or breach of professional duty?* Yes No If “Yes”, please supply details below, Date of Loss, Description, Open, Closed: After investigation, is the proposer or any principal, partner, or director aware:HiddenGeneral Informationof anyone including employees having been charged with or convicted of any criminal offence (excluding traffic offences)?* Yes No of any insurance including employees being declined or cancelled, application / proposal rejected, renewal refused, claim rejected, or special conditions or excess imposed by any insurer?* Yes No ever, either alone or jointly with others including employees been declared bankrupt or subject to any form of insolvency administration (e.g. liquidation or receivership)?* Yes No If yes to any of the above, please provide details. HiddenClaim made PolicyThis means that the policy applies to claims made against you and notified to the insurer during the policy period. The policy does not provide cover in relation to: acts, errors or omissions that occurred prior to the retroactive date (if one or more is specified) in the policy; any claim made, threatened or intimated against you prior to the commencement of the policy period; any claim or fact that might give rise to a claim, reported or which can be reported to an insurer under any insurance policy entered into before the commencement of the policy period; any claim or fact that might give rise to a claim, noted in this proposal or any previous proposal; any claim arising out of any fact you are aware of before the commencement of the policy period; any claim made against you after the expiry of the policy period. However, the effect of Section 40(3) of the Insurance Contracts Act 1984 (Cth) is that where you become aware, and notify us in writing as soon as is reasonably practicable after first becoming aware but within the policy period, of any facts which might give rise to a claim against you, any claim which does arise out of such facts shall be deemed to have been made during the policy period, notwithstanding that the claim was made against you after the expiry of the policy period. Privacy We are committed to protecting your privacy. We use the information you provide to us to arrange for and quote on the financial services we provide to you. We only provide personal information to the financial service providers (and their representatives) and those appointed to assist you with claims under policies of insurance. We will not trade, rent, or sell the information. If you do not provide us with full information, we cannot properly quote / arrange your financial products and provide the service you expect. You can check the personal information we hold about you at any time. For more information about our Privacy Policy Statement, ask us for a copy. Duty of Disclosure The law requires you to tell us everything you know (or could reasonably be expected to know in the circumstances) which is relevant to our decision to insure you and the terms on which we insure you. This duty applies before you enter into a contract with us, that is, before we accept your proposal and also each time before you alter or renew the Policy. Each person named as the Insured has the same duty. Penalty for Non-Disclosure If you do not tell us everything necessary, we may: reduce or refuse to pay a claim; or cancel your Policy. If you act dishonestly, we may invalidate the Policy from its beginning and not be bound by it. You don’t need to tell us anything which: reduces the risk; is common knowledge; we already know or ought to know in the ordinary course of our business; or we indicate we do not want to know. If you are not sure that something is relevant, it is best to disclose it anyway. Declaration and Signature The Duty of Disclosure, Non-Disclosure and Inadequate Space to Answer notices set out above have been read by me/us. All answers and statements made in this application are true and accurate in every respect and no information has been withheld which is likely to affect your decision about accepting this insurance. I acknowledge you reserve the right to decline any application. I acknowledge that you may market related products to me By signing (typing your first and last name) this declaration electronically below you agree to the above.* Signature*Date*CommentsThis field is for validation purposes and should be left unchanged.
