"*" indicates required fields Step 1 of 6 16% Your DetailsName* First Last Address* Street Address Suburb State Postal Code Contact Number*Email* Period of InsuranceStart Date* DD slash MM slash YYYY Expiry Date* DD slash MM slash YYYY Principal Business activities/Occupation InsuredInsured Name* First Last Trading Name Website address ABN Year business was established* Business Address* Street Address Suburb State Postal Code Duty of DisclosureHave you or any partner(s) or director(s) of the business:Ever had an insurance policy cancelled, declined or terms imposed?*SelectYesNoDetails*Date (DD/MM/YYYY)Description Add RemoveEver been declared bankrupt?*SelectYesNoDetails*Date (DD/MM/YYYY)Description Add RemoveEver been involved in a company or business which became insolvent or subject to any form of insolvency or voluntary administration (e.g. liquidation or receivership)?*SelectYesNoDetails*Date (DD/MM/YYYY)Description Add RemoveBeen convicted of any criminal offence within the past 5 years (other than minor traffic convictions)?*SelectYesNoDetails*Date (DD/MM/YYYY)Description Add RemoveBeen liable for any civil offence or pecuniary penalty (exceeding $5,000)?*SelectYesNoDetails*Date (DD/MM/YYYY)Description Add RemoveAny other matters you should disclose?*SelectYesNoDetails*Date (DD/MM/YYYY)Description Add RemoveClaims ExperienceHave you had any claims in the last 5 years?*SelectYesNoClaim Details*Date of Loss (DD/MM/YYYY)Claim AmountBrief description of the claimPreventative/Corrective action details Add Remove Situations and PrincipalsMain Address* Street Address Suburb State Postal Code Are there any other locations?*SelectYesNoAddress Street Address Suburb State Postal Code Principal LiabilityDo you wish to note any Principals?*SelectYesNoDetails*Name of PrincipalActivities with this Principal Add RemoveAddress Street Address Suburb State Postal Code Business DetailsType of Work* Categorise the business and professional activities and set out the approximate percentage of the turnover derived from each.*Type of WorkPercentage of turnover (%) Add RemoveTurnoverProvide the approximate percentage of your activities (based on gross turnover/fee income) applicable to each State, Territory and Overseas% NSW % VIC % QLD % SA % WA % NT % TAS % ACT % Overseas StaffTotal number of staff* Total estimated payroll* Do you engage contractors, subcontractors, or staff from labour hire firms in your business?*SelectYesNoDo you ensure that contractors and subcontractors have their own liability and where necessary, Workers Compensation insurance?*SelectYesNoEstimate the amount to be paid to contractors and subcontractors in the next 12 months:*LabourLabour and PlantLabour and Plant and Materials Add RemoveNature of work normally carried out* Do you engage labour hire or hired in labour in your business?*SelectYesNoEstimate the amount to be paid to labour hire firms in the next 12 months* Hire Equipment and/or StaffDo You, or do You intend to, hire in equipment or hire out equipment and/or staff?*SelectYesNoIs there a Hire Agreement with a disclaimer or legal waiver in place that the hirer signs before hiring?*SelectYesNoIs all equipment checked and maintained after each hire?*SelectYesNo Work Away from PremisesDo You, or do You intend to, perform work away from Your own premises?*SelectYesNoDo You, or do You intend to, perform external work over 2 storeys or 10 metres high?*SelectYesNoWhat is the Maximum height (meters)? Details of WorkDesignated Contracts : Do you have any contracts to be designated?*SelectYesNoDescription Imported Goods : Do You, or do You intend to, import goods?*SelectYesNoDetails*ProductCountryTurnover Add RemoveDo you have quality control procedures in place?*SelectYesNoPlease provide full details Are your products subject to any Australian or International standard?*SelectYesNoPlease provide full details Exported Goods : Do You, or do You intend to, export goods?*SelectYesNoDetails*ProductCountryTurnover Add RemovePlease list products that will be exported* Add RemoveDo you have quality control procedures in place?*SelectYesNoPlease provide full details* Domiciled OverseasDo You, or do You intend to, have representation outside Australia?*SelectYesNoWhere and what is the nature of your representation in each country?*CountryNature of Representation Add Remove(eg, domicile employee, power of attorney, branch subsidiary, agency, etc?)Hazardous Activities and SubstancesDo You, or do You intend to, use, store or handle hazardous substances?*SelectYesNoDetails*Type of hazardous substancesHandling and storage process Add RemoveDo You, or do You intend to, discharge waste or hazardous material into the atmosphere, sewer or elsewhere?*SelectYesNoDetails*Type of waste materialMethod of dischargeSafety procedures used Add Remove Other DetailsDo You maintain records identifying suppliers of all goods?*SelectYesNoDo You, or do You intend to, advertise your products and/or services?*SelectYesNoDetails*Type of Product/ServiceAnnual ExpenditureTypes of Media you intend to useAgency you have or intend to engage with Add RemoveLimits of LiabilityPlease indicate the total sum insured you prefer for Public and Products Liability*Select$1,000,000$2,000,000$5,000,000$10,000,000$15,000,000$20,000,000OtherPlease specify the amount* Other InformationDo you wish to provide any additional information?SelectYesNoPlease specify Consent* I agreeNon Disclosure: If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its 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. In addition to the above, following documents can be viewed on our website: PRIVACY POLICY: https://www.imcinsurance.com.au/privacy/ FINANCIAL SERVICES GUIDE (FSG): https://www.imcinsurance.com.au/financial-services-guide/ CONTACT US: IMC Insurance Brokers Pty Ltd | ABN 79 676 680 946 | AFSL 229344 Level 1 251-253 Malvern Road, South Yarra, VIC 3141 | 1300 251 253 | insure@imcinsurance.com.au Δ
