Marine Industry Insurance Declaration

Transcription

1 1. The Insured & Business Description (a) Full name and address of proposed Insured ABN (b) Telephone number (c) address (d) Full description of your Business operations and activities (e) How long have you operated the Business being proposed for insurance? (f) How long have you carried out similar work as being performed by this business? 2. Period of Insurance From DD/MM /YYYY To DD/MM /YYYY at 4pm Local Standard Time 3. Limit of Indemnity What Limit of Indemnity is required? $5 million $10 million $20 million Other 4. Details of Premises, Facilities & Work Performed (a) Details of premises occupied for the purpose of conducting the Business Location 1 Location 2 (b) Details of facilities that you own and/or operate at each location Floating Dock Yes No Number of arms Slipway Yes No Number of ramps Dry Dock Yes No Number of Docks Cranes/Cradles Yes No Number Type Weight Limit Fuel Storage Yes No i. On or over water? On Over Number of Tanks Capacity ii Land based? Underground Number of Tanks Capacity Above Ground Number of Tanks Capacity (c) Describe what type of craft, other than leisure craft, you work on (d) What proportion, if any, does this represent of your gross receipts / income % Marine Industry Insurance Declaration (04/10) Page 1

2 (e) Type of work performed by you or on your behalf Gross Receipts / Income Last 12mths Next 12 Mths REPAIR INCOME 1. Structural repairs to hulls $ $ 2. Non-structural repairs to hulls (detailing, wax, paint, etc) $ $ 3. Mechanical / Electrical repairs to hulls $ $ 4. Hot Work (away from your own premises) $ $ For 1-4 above, please describe type and size of vessels that you usually work on: MARINA INCOME 5. Mooring income $ $ Number of marina berths: Number of swing moorings:. Number of racked / dry storage berths:. 6. Fuel income $ $ 7. Property owner rental income $ $ Please provide list of tenants: 8. Hauling out / lifting / hardstand $ $ Please advise number of hardstands:. BOAT SALES 9. New & Used Boats $ $ 10. Boat Brokerage Commissions $ $ Please describe types of vessels sold: ALL OTHER PRODUCTS SALES 11. Boat Parts & Equipment (purchased from Australian Suppliers) $ $ 12. Boat Parts & Equipment (purchased from Overseas Suppliers - imports) $ $ Please describe imported equipment and advise where imported from: 13. Fuel income $ $ 14. Bar & Restaurant Sales $ $ 15. Other Goods Sold $ $ Please describe Other goods sold: OTHER INCOME 16. Marine work not otherwise listed $ $ Please describe type of Marine Work: 17. Non-marine work $ $ Please describe type of non-marine work: TOTALS $ $ (f) Please advise percentage of above work performed away from the noted location: % Marine Industry Insurance Declaration (04/10) Page 2

3 5. Fire Safety (a) How close is the nearest public fire department store (km)? (b) Are the employees of the public fire department paid or volunteers? (c) Please state the number of fire hydrants and their proximity to the yard (d) Please describe fully all fire protection facilities available, including the number of handheld fire extinguishers and the nature of any sprinkler system 6. Security (a) Is the yard fenced? (b) Please describe the nature of security measures, including watchmen 7. Estimated Payroll, Sub Contractor & Labour Hire Payments (a) Payroll (excluding payments to sub-contractors and labour hire employees) i. What is your estimated annual payroll for the forthcoming year? $ ii. How many partners or principals? (b) Sub Contractors i. Do you use the services of any sub contractors? Yes No If Yes, Estimated annual payments: $ Are payments for labour only or labour & materials? Activities undertaken: Do you ensure that your subcontractors have their own insurance? Yes No If not, are your subcontractors to be insured under this policy? Yes No (c) Labour Hire or Agency Labour i. Do you use the services of any labour hire or agency labour personnel? Yes No If Yes, Estimated annual payments: $ Activities undertaken: Marine Industry Insurance Declaration (04/10) Page 3

4 8. Care, Custody and Control Vessels i. Individual Vessel Value What is the approximate average and maximum value of the vessels being worked upon or berthed at your location: Average $ Maximum $ ii. Accumulated Vessel Values What is the average and maximum number of vessels being worked upon at any one time? Average Value $ Number: Maximum Value $ Number: iii. Vessel transport Do you road or rail transport non owned vessels? Yes No If yes, please provide details 9. Claims and/or Loss Experience (a) Have you had any insured and/or uninsured claims in the last five years? Yes If yes, please provide details below: No Date Description Amount Paid ($) Amount Outstanding ($) Applicable Excess ($) (b) After investigation, are you aware of any circumstances which could give rise to a claim under the proposed Policy and which are not mentioned above? Yes No If yes, please provide details _ 10. Insurance (a) After investigation have you ever had any: Insurance declined or cancelled? Yes No Renewal refused? Yes No Special conditions imposed? Yes No Claims denied for this class of insurance? Yes No (b) What is the inception date? (c) What is the expiring premium? DD/MM/YYYY $ Marine Industry Insurance Declaration (04/10) Page 4

5 YOUR DUTY OF DISCLOSURE Before You enter into a contract of general insurance with Us, You have a duty, under the Insurance Contracts Act 1984, to disclose to Us every matter that You know, or could reasonably be expected to know, is relevant to Our decision whether to accept the risk of the insurance and, if so, on what terms. You have the same duty to disclose those matters to Us before You renew, extend, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of matter That diminishes the risk to be undertaken by Us; That is of common knowledge; That We knows, or, in the ordinary course of Our business, ought to know; As to which compliance with Your duty is waived by Us. Non-disclosure If You fail to comply with Your duty of disclosure, We may be entitled to reduce Our liability under the contract in respect of a claim or may cancel the contract. If Your non-disclosure is fraudulent, We may also have the option of avoiding the contract from its beginning. DECLARATION I declare that to the best of my knowledge and belief the answers given above or documents submitted represent the true position and that I have not withheld any material information from this proposal. I agree that this proposal and any accompanying documents shall form or partly form the basis of the Contract Proposed. Signature(s) Title/Position Date Return to: James Finucane (phone ), IC Frith Sydney Post: Private Mail Bag 14, Castle Hill NSW 1765 Fax: james.finucane@icfrith.com.au PRIVACY NOTICE We are bound by the Privacy Act and its associated National Privacy Principles when we collect and handle your personal information. We collect personal information in order to provide our services and products. We also pass it to third parties involved in this process such as our reinsurers, agents, loss adjusters and other service providers. You can seek access to and if necessary, correct your personal information by contacting our Privacy Officer. When you give us personal or sensitive information about other individuals, we rely on you to have made or make them aware that you will or may provide their information to us, the purposes we use it for, the types of third parties that we disclose it to and how they can access it. If it is sensitive information we rely on you to have obtained their consent on these matters. If you have not done either of these things, you must tell us before you provide the relevant information. Marine Industry Insurance Declaration (04/10) Page 5