FROM 1 JULY 2015, THIS FORM MUST BE USED. NO OTHER VERSION WILL BE ACCEPTED.
QBE Insurance (Australia) Limited
628 BOURKE STREET, MELBOURNE VIC 3000
Phone: (03) 9246 2666 | Fax: (03) 9246 2611
ABN: 78 003 191 035
AFS Licence No: 239545
Victorian Managed Insurance Authority
ABN 39 682 497 841
PO Box 18409 Collins St East Victoria 8003
P: 1300 363 424
|
F: 03 9270 6949
www.dbi.vmia.vic.gov.au
Page 1 of 14
DOMESTIC BUILDING INSURANCE QM3265 06-15
APPLICATION FOR A JOB SPECIFIC POLICY
– MULTIPLE BUILDING WORKS
THREE OR MORE
DWELLINGS
ABOUT THIS FORM
This form will help us decide whether to issue a domestic building insurance policy for a MULTIPLE BUILDING WORKS (THREE OR MORE
DWELLINGS) on the one site in Victoria.
If we decide to issue a policy to the Applicant, we will rely on the information in this form. You must therefore ensure
you answer all questions truthfully.
Who should complete this form?
This form should be completed by businesses (sole traders/partnerships/companies) – hereafter referred to as “the Applicant” intending to
build three or more dwellings on the one site, this includes:
• a contract with Owners Corporations
• three or more dwellings being built for multiple owners under separate building contracts
• three or more dwellings under one building contract.
ELIGIBILITY WITH QBE/VMIA, WITH ADDITIONAL COVER FROM 1 JULY 2015
The insurance being applied for is issued by QBE Insurance (Australia) Limited (QBE) as agent for the Victorian Managed Insurance
Authority (VMIA) in accordance with the Ministerial Order for Domestic Building Insurance issued under section 135 of the Building Act 1993
(Vic), with additional cover if the Applicant fails to comply with a Tribunal or Court Order for certificates of insurance issued on or after
1 July 2015. The VMIA is a statutory corporation and is the insurer.
INFORMATION DISCLOSED IN THIS FORM AND YOUR PRIVACY
Both QBE and the VMIA are committed to safeguarding your privacy
and the confidentiality of your personal information. We will only
collect personal information from you or about you which is relevant
to processing and assessing this application, administering any
domestic building insurance policies which may subsequently be
issued, including any claims under such policies, and any recoveries
and use it in a way that you would expect. The personal information
collected may include personal details, construction details, financial
information and arrangements. Without this personal information
we may not be able to process this application or issue insurance
cover. By providing this personal information to us, you consent to us
disclosing your personal information to:
• insurance intermediaries
• insurance reference bureaus
• credit reference agencies
• our advisers
• the Victorian Building Authority or other authorities established
to regulate or report on the building industry
• those involved in the claims handling process (including
assessors and investigators) for the purpose of assisting us and
them in providing relevant reporting, regulation, services and
products, or for the purposes of litigation.
You also consent to us disclosing your personal information to:
• the owners of any building work undertaken by the Applicant
which is insured by us
• family members or agents authorised by you
• organisations which conduct customer service surveys on
our behalf
• people making enquiries as to whether a nominated builder is
eligible for domestic building insurance
• people making enquiries for details of any domestic building
insurance issued in respect of a nominated property.
Such personal information is limited to:
o policy number
o policy inception date
o property address
o name of builder
o whether a claim has been made
o the amount of any indemnity remaining under the policy.
ACCESS TO YOUR PERSONAL INFORMATION
You can request access to the personal information we hold about you by contacting:
QBE Insurance (Austalia) Limited
628 Bourke Street
Melbourne Victoria 3000
Phone: 03 9246 2666
VMIA
PO Box 18409
Collins St East Victoria 8003
Phone: 1300 363 424
DOMESTIC BUILDING INSURANCE QM3265 06-15
Page 2 of 8
SECTION 1. ABOUT THE APPLICANT
⚠
Important: You MUST notify QBE immediately if the answer is Yes to any of the following over the last 12 months:
Has the Applicant’s business structure changed (e.g. change from a sole trader to a company?)
No Yes
Have any of the directors or partners of the business changed? No Yes
Has there been a change to any of the registered builing practitioners associated with the Applicants? No Yes
QBE Policy no:
ACN: ABN:
Business address:
St a te: Po st c od e:
Telephone: Mobile:
Are you entitled to claim an Input Tax Credit on the GST component of the premium applicable to this policy?
No Yes
➡
How much – 100% or other?
PLEASE USE CAPITAL LETTERS.
A B C
Building Practitioners Registration number for each director
or partner of the Applicant who is a registered building practitioner,
or if the Applicant is a sole trader, you:
What is the name of the building entity (business) for which cover
is sought (“the Applicant”)?
⚠
This name must EXACTLY MATCH the building contract.
If these details are not correct, the VMIA may refer the matter to
the Building Practitioners Board to enquire into the conduct of the
relevant registered building practitioners.
DOMESTIC BUILDING INSURANCE QM3265 06-15
Page 3 of 8
SECTION 2. CONTRACT DETAILS
Please specify the category of the multiple building works being completed (tick applicable):
Contract with Owners Corporation (Go to Section 2a).
Three or more dwellings being built for multiple owners under separate building contracts (Go to Section 2b).
Three or more dwellings under one building contract (Go to Section 2c).
2a. CONTRACT WITH OWNERS CORPORATION
📎
Please attach the Scope of Works and the building contract (if applicable).
Owners Corporation (OC) name:
OC number:
Registered OC address:
St a te: Po st c od e:
What is the contract price? (inc GST)
Signed contract date: Estimated start date: Estimated completion date:
Please describe the scope of works to be undertaken for the common property and the value for each item.
Describe scope of works Estimated Value
$
$
$
$
$
Is any work to be undertaken outside of the common property area (e.g. to a dwelling/s)?
No Yes
➡
Please provide details:
Describe scope of works and the unit number/s Estimated Value
$
$
$
$
$
$
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D D M M Y Y Y Y
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D D M M Y Y Y Y
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DOMESTIC BUILDING INSURANCE QM3265 06-15
Page 4 of 8
2b. THREE OR MORE DWELLINGS BEING BUILT FOR MULTIPLE OWNERS UNDER
SEPARATE BUILDING CONTRACTS
⚠
Note: This section applies where there is a requirement for common works, such as:
• A common driveway • Construction of a road • Construction of a fire rated wall between adjoining units
📎
Please attach plans and specifications AND the building contract for EACH dwelling.
Estimated start date: Estimated completion date:
Please provide details and value of any non-residential works included in the development contract/construction price
(e.g. shops, commercial office, infrastructure works such as roads, etc):
Describe scope of works Estimated Value
$
$
$
$
$
2c. THREE OR MORE DWELLINGS UNDER ONE BUILDING CONTRACT
📎
Please attach plans and specifications AND the building contract for EACH dwelling.
Signed contract date: Estimated start date: Estimated completion date:
Please provide details and value of any non-residential works included in the development contract/construction price
(e.g. shops, commercial office, infrastructure works such as roads, etc):
Describe scope of works Estimated Value
$
$
$
$
$
Name of the Bank/Financier to the project:
📎
Please attach a copy of the final and accepted loan approval as issued by the Financier.
📎
Please attach evidence of funds if self funded.
/
D D M M Y Y Y Y
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D D M M Y Y Y Y
/
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D D M M Y Y Y Y
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D D M M Y Y Y Y
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D D M M Y Y Y Y
/
DOMESTIC BUILDING INSURANCE QM3265 06-15
Page 5 of 8
SECTION 3. DEVELOPMENT AND CONSTRUCTION/TYPE
Description of the development (e.g. Six new freestanding double storey brick veneer townhouses with slate roof and double garage).
New development? No Yes
AND/OR
Renovation/Refurbishment of an existing building? No Yes
➡
Please provide details:
Is this part of a staged construction?
No Yes
➡
Please provide details:
What stage? How many stages are there?
Will any pre-existing buildings remain on the site following the completion of this contract?
No Yes
➡
Please provide details:
Has construction commenced? No Yes
Will any part of the development (including landscaping) be constructed under another contract?
No Yes
➡
Please provide details:
Number of residential levels: Number of residential units total:
Number of parking levels:
Above ground: Below ground:
Lifts : No Yes
Page 6 of 8
DOMESTIC BUILDING INSURANCE QM3265 06-15
SECTION 4. SITE LOCATION AND LOT VALUE DETAILS
For 2b and 2c, please complete for EACH dwelling on the site. If there are more than the space available below, please attach this information for all units.
Lot
no.
Contract
signed
Owner/developer
name
Is there any relationship
between the owner/
developer and builder?
If yes, explain relationship.
Unit
no.
Street
no.
Street name Suburb Postcode
Current postal address of
owner/Owners Corporation
Estimated value
of lot/unit
under contract
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DOMESTIC BUILDING INSURANCE QM3265 06-15
Page 7 of 8
SECTION 5. INFORMATION CHECKLIST AND FURTHER DISCLOSURES
The following information/documentation must accompany this application:
Copy of executed Building Contract. Note: If the building contract hasn’t yet been executed, you must provide the requested documents
within 7 days of the building contract being signed.
Site plans and ground floor plans.
For 2c you will also need to supply the following:
Evidence of ownership (subject property must be in the same name as the Developer e.g copy of Rates Notice or copy of signed Transfer
of Land if ownership has not yet been registered, or a copy of the signed Contract of Sale if settlement has not yet been effected).
Final Terms and Conditions/ Letter of Offer from the Financier.
Evidence of available funds if the project is to be fully or partially self funded.
⚠
This section must be completed by the Registered Building Practitioner who is a director or partner of the Applicant; or the Applicant if
you are a sole trader and a Registered Building Practitioner; or a person who has been nominated by the Applicant to complete this
application on its behalf by way of execution of the QBE/VMIA Nomination and Authority form.
Has there been a change to any of the directors or partners of the Applicant who are registered building practitioners since the Applicant
applied for eligibility for domestic building insurance?
No Yes
➡
Please provide details:
Have you become aware of any circumstance since the Applicant applied for eligibility for DBI insurance that may give rise to a claim
against you or the Applicant in respect of any domestic building work?
No Yes
➡
Please provide details:
Has the building licence/registration of any directors or partners of the Applicant who are building practitioners – or, if the Applicant is a
sole trader, has your registration as a building practitioner been cancelled, suspended or varied since the Applicant applied for eligibility for
domestic building insurance?
No Yes
➡
Please provide details:
Is there any further information or matter of a material nature not otherwise disclosed in this application that:
• could significantly affect the financial position of you or the Applicant?
• might influence QBE’s acceptance of this application on behalf of the VMIA or the terms upon which the application is accepted?
• might influence QBE’s decision to issue domestic building insurance on behalf of the VMIA to the Applicant?
No Yes
➡
Please detail further information or relevant matters:
DOMESTIC BUILDING INSURANCE QM3265 06-15
Page 8 of 8
SECTION 6. APPLICANT’S DECLARATION
⚠
This section must be completed a Registered Building Practitioner who is a director or partner of the Applicant; OR the Applicant if you
are a sole trader and a Registered Building Practitioner; OR a person who has been nominated by the Applicant to complete this
application on its behalf by way of execution of the QBE/VMIA Nomination and Authority form.
1. Declared by (name):
Position/title:
For and on behalf of
(name of Applicant entity):
Signature:
2. Declared by (name):
Position/title:
For and on behalf of
(name of Applicant entity):
Signature:
3. Declared by (name):
Position/title:
For and on behalf of
(name of Applicant entity):
Signature:
4. Declared by (name):
Position/title:
For and on behalf of
(name of Applicant entity):
Signature:
✎
✎
✎
✎
Date:
Date:
Date:
Date:
I acknowledge that:
• QBE and the VMIA have the right to decline any Application for a Job Specific Multiple Building Works policy.
• QBE and the VMIA reserve the right at all times to seek additional information from the builder and all other parties to this application.
• The details provided in this application are true and correct.
• At the date of signing of this application, the Applicant is solvent.
• For certificates of insurance issued on or after 1 July 2015, in addition to cover provided in accordance with the Ministerial Order, the owner is also
entitled to make a claim if the Applicant fails to comply with a Tribunal or Court Order.
I authorise QBE and the VMIA to give to, or obtain from, other insurers or insurance reference bureaux, credit reporting agencies, their advisers, the
Victorian Building Authority or other authorities established to regulate or report on the building industry, those involved in the claims handling process
(including assessors and investigators) and those involved in any way in connection with building work insured under any domestic building insurance
policy issued as a result of this application, including those people making enquiries as identified on page 1 of this form, any information about or
contained in this application, any domestic building insurance policy subsequently issued, and any claims and recoveries, including this completed
application and my and the Applicant’s claims and credit history.
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D D M M Y Y Y Y
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D D M M Y Y Y Y
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D D M M Y Y Y Y
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D D M M Y Y Y Y
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