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General Liability
Proposal Form
Completing the Proposal Form
1. This application must be completed in full including all required attachments.
2. If more space is needed to answer a question, please attach a separate sheet with details.
3. The term Insured, whenever used in this proposal form shall mean the insured listed and all subsidiary companies of the Insured
for which coverage is proposed under this proposal or in the policy.
Some sections of the application will not apply to your rm. Where this is the case, please mark “not applicable (N/A)”.
1. General Information:
Proposed period of insurance: From To at 4pm, local time
Name of Insured (Include names of all subsidiary or aliated companies and a company structure diagram):
1. 4.
2. 5.
3. 6.
Head Oce Address:
ABN:
Year commenced business:
Please provide a detailed business description of your full operations:
Please list your website address/es:
1.
2.
3.
Total number of Locations:
Please list and indicate –
Owned (O), Leased (L), Retail (R),
Oce(OF), Warehouse (W)
Location 1:
Location 2:
Location 3:
Location 4:
Total number of employees: Full Time Equivalent (FTE): Part Time Equivalent (PTE):
Payroll: $
Total turnover ($000’s) $
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2. Limit of Liability:
Tick the Limit of Liability required for General Liability and if applicable Products Liability in any one Period of Insurance:
$5 Million
$10 Million
$20 Million
$50 Million
Other
$
Deductible applicable to General and Products Liability:
$1,000
$2,500
$5,000
$10,000
$25,000
$50,000
$75,000
$100,000
Other
$
3. General Operations:
A. Business Activities (please list as a percentage of total revenue):
Business Activity Revenue Raw Material Component/Sub Assemblies Completed/Finished Goods
Manufacturer % % %
Wholesaler/ Retailer % % %
Importer % % %
Exporter % % %
Distributor Only % % %
Service/Repair/Maintenance/
Installation (please specify)
Other
B. Products (If N/A please continue to ‘C’ on page 3)
N/A
Are any third party supplied products repackaged or modied in any way after arrival? If Yes please provide details:
Yes
No
Please provide/attach details of end use/application and approximate total sales value for any insured products:
Product Description/End Use Estimated Annual Turnover Country or Countries sold to
Please provide or attach details of any discontinued product:
Turnover (% – by State or Territory or Overseas)
NSW VIC ACT QLD SA WA TAS NT O/S
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E. Suppliers and raw materials (Attach any further relevant information):
Please provide details of raw material suppliers including country of origin and value:
Product Country of Origin Value ($) or Percentage (%) of total raw materials
Please provide a description or copy of your “Supplier Approval Program”:
5. Contract Review/Standard Terms and Conditions of Trade:
Do you have a standard signed contract or purchase order with every customer?
Yes
No
Do you engage internal or external legal counsel to review of all standard contracts, agreements and marketing materials
prior to release?
Yes
No
Please attach or give full details of all contractual liabilities, waiver of rights of recourse or “hold harmless” agreements given by or to sellers,
suppliers or direct customers:
D. Mergers or Acquisitions or Divestitures:
Have you purchased any companies during the past year? If Yes, please provide details (i.e. Assets or liabilities as part of
the acquisitions):
Yes
No
Does the proposer own or use any unregistered vehicles or mobile plant and equipment?
Please provide details of number and type:
Yes
No
Please list or attach any operations and associated controls that may include production distribution, storage, disposal or transport of Toxic
and/or Hazardous substances that could potentially cause bodily injury and/or property or environmental damage:
If there is storage, what is the Capacity (L)? Bunded Capacity (L)?
C. General Liability Information
Are any of your services or products used in or for aircraft, watercraft, hovercraft, Military, Critical Component or Life Safety
related products or activities? If Yes, please detail or attach any relevant information:
Yes
No
Do you and your supplier’s labels and instruction manuals describe and warn against potential hazards and/or misuse in
accordance with legislative standards? If Yes, please detail and/or attach any relevant standards of compliance, examples
of warnings labels and/or instruction manuals:
Yes
No
AS NZS or International Standard/Labels/Manuals: Description:
e.g. CE, TUV or UL AS NZS e.g. 8124: Safety of Toys
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7. Quality assurance and Risk Management:
Please list any International Risk Management (i.e. ISO), Quality Assurance (i.e. HACCP, SQF) and or Good Manufacturing Practice programs you
have in place (please attach any relevant Information including details of quality control procedures and laboratory testing used).
ISO/HACCP/Testing Accreditation Date of last audit Audited by Please specify if
e.g. ISO 9001:2008 21/7/16 SAI Global
Interal
External
Interal
External
Interal
External
Interal
External
Is there backwards traceability for ingredients/components and/or packaging used in the manufacturing of products or
services? Please detail or attach details:
Yes
No
Does the proposed insured maintain a current recall program? Please provide details:
Yes
No
Please list any type of security measures on site with regards to visitors, contractors and employees:
Please describe or attach a copy of your current contractor vetting process:
Is there a formal procedure for ensuring contractors have Workers Compensation (WC) and General Liability (GL) policies
in place? If Yes, please detail or attach any requirements? i.e. Certicates of currency (at least 10 million for GL).
Yes
No
6. Subcontractors, Independent Contractors and Labour Hire:
Do you use Subcontractors, Independent Contractors or Labour Hire?
Yes
No
Please provide details of annual payroll for contractors/subcontractors, labour hire or people engaged on the proposer’s premises?
Service Provided Approx. Labour only payments ($000’s) Contractor Name
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False Information
Before you enter into a contract of general insurance with us, you have a duty under the Insurance Contracts Act 1984 (Cth) to disclose to us every
matter you know, or could reasonably be expected to know, is relevant to our decision whether to insure you and, if so, on what terms.
This applies to all persons to be covered under this contract of insurance.
Any person who, knowingly and with the intent to defraud any insurance company or other person, les a proposal for insurance
containing any false information, or conceals for the purpose of misleading, information concerning any fact material thereto,
commits a fraudulent insurance act, which is a crime.
Duty of Disclosure
Your Duty of Disclosure
Before you enter into an insurance contract, you have a duty to tell us anything that you know, or could reasonably be expected to know, may
aect our decision to insure you and on what terms.
You have this duty until we agree to insure you.
You have the same duty before you renew, extend, vary or reinstate an insurance contract.
What you do not need to tell us
You do not need to tell us anything that:
• reduces the risk we insure you for; or
• is common knowledge; or
• we know or should know as an insurer; or
• we waive your duty to tell us about.
If you do not tell us something
If you do not tell us anything you are required to, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both.
If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed.
9. Additional Coverage’s required (Where necessary please contact your broker or Chubb Insurance Australia
Limited for further details):
Care, Custody and Control
Yes
No
Limit required:
Umbrella Liability
Yes
No
Limit required:
Statutory Liability
Yes
No
Limit required:
Recall Expenses
Yes
No
Limit required:
Environmental Protection (gradual) Liability
Yes
No
Limit required:
Errors and Omissions Liability
Yes
No
Limit required:
8. Claims Experience:
Have you had any insured or uninsured losses over the last ve years that would have been covered under the proposed insurance.
Alternatively, please provide updated claims experience for 5 years on Insurers letterhead.
Incident date Description Outstanding ($) Amount Paid ($) Deductible ($) Remedial action initiated
Are you aware of any circumstance, which may be expected to result in a claim or an allegation being made against you?
If Yes, please detail:
Yes
No
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About Chubb in Australia
Chubb is the world’s largest publicly traded property and casualty insurance company. With operations in 54 countries, Chubb
provides commercial and personal property and casualty insurance, personal accident and supplemental health insurance,
reinsurance and life insurance to a diverse group of clients. As an underwriting company, we assess, assume and manage risk with
insight and discipline. We service and pay our claims fairly and promptly. The company is also dened by its extensive product
and service oerings, broad distribution capabilities, exceptional nancial strength and local operations globally. Parent company
Chubb Limited is listed on the New York Stock Exchange (NYSE: CB) and is a component of the S&P 500 index. Chubb maintains
executive oces in Zurich, New York, London and other locations, and employs approximately 31,000 people worldwide.
Chubb, via acquisitions by its predecessor companies, has been present in Australia for over 50 years. Its operation in Australia
(Chubb Insurance Australia Limited) provides specialised and customised coverages, including Marine, Property, Liability, Enery,
Professional Indemnity, Directors & Ocers, Financial Lines, Utilities, as well as Accident & Health insurance, to a broad client base.
Chubb is a major insurer of many of the country’s largest companies. With ve branches and over 500 sta in Australia, it has a
wealth of local expertise backed by its global reach and breadth of resources.
More information can be found at www.chubb.com/au
Contact Us
Chubb Insurance Australia Limited
ABN: 23 001 642 020 AFSL: 239687
Grosvenor Place
Level 38, 225 George Street
Sydney NSW 2000
O +61 2 9335 3200
www.chubb.com/au
General Liability Proposal Form, Australia. Published 11/2017.
©2017 Chubb Insurance Australia Limited. Chubb®, its logos, and Chubb.Insured.
SM
are protected trademarks of Chubb. Chubb021071117
Declaration
1. (I/We) have read the Important Notices at the head of this Proposal.
2. (I/We) declare that the answers above are true and correct and I/We have discharged my/our duty of disclosure.
3. (I/We) agree that the person completing this Proposal wholly or in part does so as my/our agent and not that of Chubb Insurance
Australia Limited.
Date
Proposer’s Signature:
Title:
Name:
Please attach copies of your standard contracts or agreements.
