Step 1 of 8 - Personal Details 12% Can I start with your personal Details?HiddenContact DetailsName* First Last Email* Phone* Nice to meet you! Please tell about your BusinessBusiness 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 FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Year Business Established Tell us more about your BusinessHiddenBusiness InformationTick the Relevant Activities Key cutting Re-key Locks Restricted Master Key Systems Electronic Security Install locks Door installation Security monitoring 24 emergency service Alarm installation Alarm monitoring Fitting security screen doors CCTV Safe Installations & Safe Sales Safe Picking Change safe combinations Security Audits Repair or replace broken locks Home security advice Lock sales Forensic Locksmithing Transponder cloning Automotive lock-outs Domestic lock-outs Install door closers Keys cut to code Commercial Door Hardware Window locking devices Hardware sales Supply & repair of remotes Home automation Estimated Turnover for the next 12 months*Actual turnover last 12 months*Number of Proprietors / Partners / Principals Giving Advice Number Of Workers (e.g. Directors / Employees / Labour Only Sub Contractors / Work Experience)Confirm Experience Of Proprietors/Partners/Directors/Principals Exceeds 1 Year?* Yes No Turnover Split By StateNSWVICQLDWASANTACTTASTotalMust equal 100%Consent Are you a small business eligible for the exemption from the requirement to pay NSW Stamp Duty on certain types of insuranceNote, 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 Great! List your limits of IndemnityHiddenLimits of IndemnityLimits of Indemnity Public Liability: $20,000,000, Professional Indemnity: $1,000,000, Loss of Keys $250,000, Statutory Liability $500,000 Public Liability Only Public Liability Only $5,000,000 $10,000,000 $20,000,000 Have You or any director or partner involved with the Business or any other business have in the past 5 yearsHiddenGeneral DetailsEver Been Declared Bankrupt Or Insolvent Yes No Ever Been Convicted Of Or Charged (But Not Yet Tried) Or Been Given An Official Police Caution In Respect Of Any Criminal Offence Other Than A Motoring Offence Yes No Ever Had Any Previous Insurer Decline A Proposal, Refuse To Renew A Policy Or Impose Special Terms Or Conditions Yes No Ever Been Convicted Of Any Offence Relating To The Health And Safety Of Your Employees Or Members Of The Public In Connection With Your Business Yes No If Yes, Please Provide Full Details Provide your Claim History - Professional Indemnity and LiabilityHiddenClaim History - Professional Indemnity & LiabilityHas the Applicant, including all directors, officers, employees had any claims made against you (whether insured or not) or have you recalled any of your products during the last 7 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 professional negligence or breach of professional duty been made in the last 10 years against any Applicant (including all directors, officers, employees) or any of their predecessors in business, or any prior business of any of their present or former directors, partners, or principals?* Yes No Do any circumstances exist that might give rise to a claim against an Applicant or any director, officer, employee or agent for 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 anyone including employees having been charged with or convicted of any criminal offence (excluding traffic offences)?* 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 By signing (typing your fist and last name) this declaration electronically below you agree to the above.* SignatureDate*EmailThis field is for validation purposes and should be left unchanged.
