Entity / Trading Name(s) / Business Commencement Date
Periods and Limits of Insurance
Business Operations Outside Australia
Include product, use of product, and estimated turnover for the next 12 months. Please email product brochures or other relevant documents to firstname.lastname@example.org
Use of Certain Machinery / Chemicals etc
Include details of chemical name, quantity, and details of storage
Claims / Insurance History
Include date, particulars, cost, and name of insurer (if any)
Declaration for an on behalf of Named Insured *
I/We declare and warrant that after enquiry all statements and particulars contained in this proposal and addenda are true and that no information whatever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this proposal and should the above particulars alter in any way I/We will advise the Underwriters as soon as practicable.
I/We understand that failure to disclose any material facts which would be likely to influence the acceptance and assessment of the proposal may result in the Underwriters refusing to provide indemnity or voiding the policy in every respect.