Public Liability Renewal Declaration

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Work Request ID

Your Information

Name*

Business Name

ABN

Email*

Best Contact Number*

Website

Address*

Business Information

Total business turnover for past 12 months*

Estimated total business turnover for next 12 months*

Total wages paid in past 12 months*

Number of Full-Time equivalent staff members over the past 12 months*

Total wages estimated for next 12 months*

Estimate of Full-Time equivalent staff members for next 12 months*

What states does your business operate in?

Percentage of turnover from NSW*

Percentage of turnover from VIC*

Percentage of turnover from QLD*

Percentage of turnover from SA*

Percentage of turnover from WA*

Percentage of turnover from TAS*

Percentage of turnover from NT*

Percentage of turnover from ACT*

Percentage of turnover from Overseas*

If Overseas, please advise further details*

NSW Stamp Duty Declaration

Are you a small business Individual / Partnership / Company and/or Trust, which is carrying on a business, and the business has an aggregated turnover of less than $2 million*

Yes
No

Aggregated turnover is your Australia wide annual turnover plus the annual turnovers of any business entities that are your affiliates or are connected with you.

Click here to read more about this exemption

About Your Business

Please describe your business activities and/or occupation*

Has there been any notable changes made to your business activities in the last 12 months?*

Yes there has
No there hasn't

If yes, please provide further details*

Do you regularly work away from your usual business location?*

Yes we do
Not at this stage, but maybe in the future
No we dont

Percentage of your turnover received from this work*

Is your business involved with any of the following?*

Welding
Underground Work
Off-shore Platform Work
Aircraft, Watercraft or Hovercraft
Rail Equipment or in the Rail Corridor
Blasting
NONE OF THE ABOVE

Please provide further details of this work*

Contractors & Labour Hire

Do you engage contractors for any of your work?*

Yes
No

Type of work Contractors undertake on your behalf?*

Estimated fees paid to contractors for LAST 12 months*

Estimated fees paid to contractors for NEXT 12 months*

Do you enter into contracts with each and every contractor?*

Yes I do
No I dont

Do all contracts have an indemnity or waiver of subrogation in your favour?*

Yes they do
No they dont
I am unsure

If NO, please explain the steps you take to minimise injuries to your contractors?*

Do you require all contractors to have their own insurances in place?*

Yes we do
No we don't
I am unsure

Do you view and retain a copy of their current liability certificate of currency?

Yes, for all contractors
Yes, for some contractors
No we dont
I am unsure

Do you hire out any employees to third parties on a Labour-Hire basis?*

Yes I do
No I dont
Not at this stage but maybe in the future

Estimated Turnover / Income received from Labour-Hire?*

What activities will they undertake?*

Products Insurance

With regards to Products, do you*

Manufacture
Import
Export
Re-Package
Distribute
WE DO NOT HAVE ANY PRODUCTS

Are any of your products used in or at*

Aircraft
Vehicles
Watercraft
Hovercraft
Rail Equipment
Power Stations
Chemical / Petrochemical Plants
Mining / Drilling Sites
NONE OF THE ABOVE

Do you have quality control procedures in place for all of your products?*

Yes
No

Have you ever recalled a product because of a potential safety hazard?*

Yes
No

Manufactured Products

Products Manufactured*

Turnover from Manufactured Products*

Can you identify the source of every item used in their Manufacture?*

Yes
No

Imported Products

Products Imported*

Turnover from Imported Products*

Countries of Origin for Imported Products*

Do you modify Products that you Import?*

Yes
No

Are imported products compliant to Australian Standards, applicable for their intended use?*

Yes they are
No they are not
Unsure / Can't confirm

Exported Products

Products Exported*

Turnover from Exported Products*

Countries of Origin for Exported Products*

Do you modify Products that you Export?*

Yes
No

Re-packaged Products

Products Re-Packaged*

Turnover from Re-Packaged Products*

Other than Re-Packaging, do you modify these Products in any way?*

Yes
No

Distributed Products

Products Distributed*

Turnover from Distributed Products*

Do you modify Products that you Distribute?*

Yes
No

Coverage Required

Level of Cover Required*

Please advise limit of cover required*

Contract Liability

Have you or will you sign any contracts (Other than for a property lease)*

Yes, I have signed a new contract in the past 12 months
Yes, I will be signing a contract shortly
No, I haven't signed a contract
I am unsure for now

If you have or will be signing a contract, will you assume liability or hold any party harmless*

Yes, I will
No, I wont
I am unsure

If yes, please upload a copy of the relevant contracts

Drop files here or

Max. file size: 32 MB.

Claims Declaration

After enquiry, are any of the Partners, Principals, Directors or Employees aware of any claim, or fact, or circumstance which has the potential to give rise to a claim against the business?*

No, I have nothing new to notify
Yes, I have something new to notify
Yes, I have previously notified you

If yes, please provide further details*

Other Insurances

Do you require a quote on any alternative insurance covers that you do not currently hold with Webber Insurance?*

If other, please advise details*

Important Information

Please take a moment to read these important documents prior to submitting your form.

Declaration

I/WE declare that we have read the important notices attached above and I/WE understand those notices.
I/WE undertake to inform insurers of any material alteration to these facts whether occurring before or after completion of the Contract of Insurance.
I/WE hereby acknowledge that the insurance cover may be provided in whole or in part by overseas insurers.

Please tick all to confirm that you have read the following documents:*

Financial Services Guide
Privacy Policy
Duty of Disclosure
Terms of Engagement

Signature

This electronic signature will be treated the same as if signed personally.

Signature

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Public Liability Renewal Declaration

Your Information

Business Information

NSW Stamp Duty Declaration

About Your Business

Contractors & Labour Hire

Products Insurance

Manufactured Products

Imported Products

Exported Products

Re-packaged Products

Distributed Products

Coverage Required

Contract Liability

Claims Declaration

Other Insurances

Important Information

Declaration

Signature

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