APPLICATION FORM IMPORTANT INFORMATION FIRE PROTECTION PUBLIC AND PRODUCTS LIABILITY INSURANCE INSURER AND AGENT DEFINED TERMS

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1 FIRE PROTECTION PUBLIC AND PRODUCTS LIABILITY INSURANCE APPLICATION FORM IMPORTANT INFORMATION INSURER AND AGENT Calibre Commercial Insurance Pty Ltd (ABN , AFSL ) ( Calibre Insurance ) acts under a binder as agent for Great Lakes Insurance SE (ARBN , ABN , AFSL ) trading as Great Lakes Australia ( GLA ). Great Lakes Insurance SE is a limited liability company incorporated in Germany. In all aspects of arranging this Policy, Calibre Insurance acts as an agent for the Insurer and not for You. DEFINED TERMS Some words used in this Application Form ( Application ) have a special meaning as defined in the Policy wording and such other documents which make up the Policy which contain definitions. GENERAL INSURANCE CODE OF PRACTICE GLA is a signatory to the General Insurance Code of Practice ( the Code ). The Code aims to raise standards of service between insurers and their customers. Calibre Insurance s service standards are in accordance with the Code. For any information about the Code, including a copy of the Code, contact Us or the Financial Ombudsman Service Limited ( FOS Australia ) on (or 1800 FOS AUS) or visit YOUR DUTY OF DISCLOSURE (please read carefully) 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 affect 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. 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. After the Policy is entered into, ongoing disclosure obligations apply. See the Policy for details. PRIVACY Both GLA and Calibre Insurance are committed to the safe and careful use of Your personal information in the manner required by the Privacy Act 1988 (Cth), the Australian Privacy Principles and the terms of the Policy. Calibre Insurance and/or GLA collect Your personal information in order to assess Your Application for insurance and, if Your Application is accepted, to administer and manage the Policy and respond to any claim that You make. To do this, Your personal information may need to be disclosed to reinsurers, service providers and related entities who carry out activities on Our and Calibre Insurance s behalf, such as assessors and facilitators, some of whom may be located in overseas countries. Our contractual arrangements generally include an obligation for these reinsurers, service providers and related entities to comply with Australian privacy laws. By providing Us and Calibre Insurance with Your personal information, You consent to the disclosure of Your personal information (including sensitive information) to reinsurers, service providers and related entities in overseas countries to enable Us and Calibre Insurance to assess Your Application, to administer and manage the Policy and to respond to any claim that You make. Your personal information (including sensitive information) may be disclosed to entities in the following countries: Canada, Germany, India, Singapore, South Africa and the United Kingdom. If You consent to the disclosure of Your personal information to overseas recipients, and the overseas recipient handles Your personal information in a way other than in accordance with the Australian privacy laws, We and Calibre Insurance may not be responsible for the handling of Your personal information by the overseas recipient. If You choose not to provide Your personal information and/or choose not to consent and/or withdraw Your consent to the disclosure of Your personal information to overseas entities at any stage, We and/or Calibre Insurance may not be able to assess Your Application or administer and manage the Policy and respond to any claim that You make. Our and Calibre Insurance s privacy policies contain information on how You may access personal information that each of Us hold, or seek correction of Your personal information and information on how to make a complaint about the handling of Your personal information and how complaints are handled. If You require more information, You can access the GLA Privacy Policy and Privacy Statement at or Calibre Insurance s Privacy Policy at and Privacy Statement at SUBROGATION RIGHTS If You have entered into an agreement with another party which prevents Us from taking a recovery action for compensation from that party it may affect Your rights to cover under this Policy. Should You now be a party to such agreement or be requested to enter such an agreement in the future please advise Us immediately in writing. FORM COMPLETION Please answer all questions. Please tick appropriate boxes and provide details as requested. If there is not enough space provided to answer a question please complete Your answer on a separate page and attach it to the Application. 1

2 THE APPLICANT Named Insured List all entities including subsidiary companies, that You require to be specified as the named Insured: Business Address State Postcode Postal Address State Postcode ABN Tax Status: Registered Business Yes No Taxable Telephone No Fax No Address Website Address Note: Provision of Your website does not alleviate You of Your Duty of Disclosure. DETAILS OF YOUR BUSINESS State full details: PERIOD OF INSURANCE Commences 4pm on / / and ends 4pm on / / Limit of Liability Please state the required Limit of Liability: 10,000,000 20,000,000 Other Amount Date the Business was established / / Are You a member of the Fire Protection Association of Australia (FPAA) or NSW Plumbers Association? Yes No If Yes, please advise Your membership number Please advise Your membership category: Bronze Silver Gold Platinum 2

3 1. Estimated Annual Payroll (Including earnings of principals, directors, partners) Do You engage any contractors and/or sub-contractors? Yes No If Yes, please advise: a) Nature of work performed b) Estimated annual labour payments to such contractors and/or sub-contractors c) Do You obtain Certificates of Currency for liability insurance held by contractors and/or sub-contractors? Yes No d) Are You always named as principal on the contractors and/or sub-contractors liability policies? Yes No Do You utilise any Labour hire personnel? Yes No If Yes, please advise: a) Nature of work performed b) Estimated annual labour payments for such labour hire personnel 2. Estimated Annual Turnover Please split Your estimated annual turnover by State: (ensure it adds up to 100) NSW VIC QLD SA NT ACT TAS WA Overseas 3

4 Please split Your estimated annual turnover by activity performed: (ensure it adds up to 100) Category Activities Percentage A B Supply, servicing, maintenance, testing & installation of portable fire protection equipment including fire extinguishers, fire hose reels & fire hydrants i) Supply, servicing, maintenance, testing & installation of electrical fire protection products including emergency & exit lighting, fire alarm panels & pumps ii) Supply, servicing, maintenance, testing and installation of passive fire protection products iii) Testing only of fire sprinkler alarm systems C Servicing, maintenance & installation of sprinkler systems D Retail & wholesale product sales of fire protection equipment &/or products E Design &/or consulting engineers in respect of fire protection systems F Certification of fire protection systems &/or fire building audits G Training Services: (provide details of the type of training provided) H Fire Protection surveying & investigative work including bushfire assessments L Other activities: (please list with for each) M NSW plumbing (excluding servicing, maintenance & installation of sprinkler systems) 3a. Do You require Consumer Protection Cover for Your Queensland Electrical Contractors? Yes No If Yes, please advise: Name(s) of Queensland electrical contractor licence holders Licence number 3b. Do You require cover for Victorian plumbers warranty? Yes No If Yes, please advise: Name(s) of Victorian licensed plumbers Licence number 4

5 4. Is any work performed by You or on Your behalf on or within any Watercraft exceeding 20 metres in length or any floating off-shore gas or oil platforms? Yes No If Yes, please advise the details of such work as follows: a) Estimated annual turnover b) Your maximum contract value in respect of any one contract c) Type of work performed: 5. Is any work performed by You or on Your behalf on or within any of the following? Airports Yes No Fixed off-shore gas or oil platforms Yes No Petrochemical plants or refineries Yes No Power stations Yes No Mines (above ground or open cuts) Yes No Underground mines Yes No If You have answered Yes to any of the above please advise precise details of the work performed. Relevant details: 6. Have You entered into any contract or agreement (including any in respect of the supply of raw materials, components or finished goods) under which You have assumed liability for which You would not otherwise be liable, or under which You have waived Your legal rights of recovery (eg. hold harmless agreements)? If Yes, please provide details and attach copies of the contract or agreement. Yes No 5

6 7. Do You perform any activities outside Australia? Yes No If Yes, advise type of activities and countries where this is conducted. YOUR PRODUCT DETAILS Your Products mean any goods, products or property after they have ceased to be in Your possession or under Your control which are, or are deemed by law to have been manufactured, grown, extracted, produced, processed, assembled, constructed, erected, installed, altered, repaired, serviced, treated, renovated, sold, supplied, distributed, imported or exported by You or on Your behalf including labels, packaging or any container thereof, the design, specification or formula of the goods, products or property and directions, instructions or advice given or omitted to be given in connection with such goods, products or property. (Please read the above definition of Your Products prior to completing Questions 8, 9, 10, 11 and 12) 8. Have any of Your Products been discontinued during the past 10 years? Yes No If Yes, please list the goods or products and advise the reason for discontinuance. 9. Exports Are any of Your Products exported? Yes No If Yes, please provide details of: a) Estimated annual turnover derived from exports b) Countries to which Your Products are exported c) Countries in which You have a branch or subsidiary company Note that exports to USA or Canada are specifically excluded by this Policy, refer to exclusion 4.10 of this Policy. 10. Imports Are any of Your Products imported? Yes No If Yes, please provide details of: a) Countries from which You import b) Describe the goods or products imported 6

7 11. Quality Control Do Your Products comply with all relevant Australian Standards? Yes No If No, please provide the reason for non-compliance: 12. Product Details Have any of Your Products been recalled during the past 10 years? Yes No If Yes, please provide details: Date of Recall Reason for Recall Number of Units Involved INSURANCE HISTORY a) Within the last seven years has any incident occurred or claim been made against You involving Personal Injury to any person not being Your employee or damage to property of others? Yes No If Yes, please provide details: Date of Loss Cause of Claim/Incident Amount of Claim / / / / / / / / b) Has any insurer ever declined, refused to renew, cancelled or imposed special terms or conditions to any application, renewal or policy held by You? Yes No If Yes, please provide details: 7

8 DECLARATION This Declaration must be completed and signed by or on behalf of all parties making this Application. I/We have read and understood the clauses detailed under the Important Information section (including the duty of disclosure) included in this Application. I/We confirm that the answers and statements in this Application are correct and that no information has been withheld which may affect the decision to accept this Application or the terms and conditions of any insurance provided. I/We understand that if this Application is accepted the insurance cover will be subject to the Policy terms and conditions. I/We further acknowledge that Calibre Insurance on behalf of GLA, their agents or employees reserve the right to decline this Application. I/We acknowledge that the personal information Calibre Insurance collects from me/us is collected on behalf of GLA for the purpose of processing this Application, fulfilling Calibre Insurance s obligations in providing services to me/us, for the development of products and services, and to allow Calibre Insurance and its related entities to market products and services. If I/we do not provide relevant information, I/we acknowledge that Calibre Insurance on behalf of GLA may be unable to process my/our Application. I/We acknowledge that information may be disclosed to: Intermediaries through which I/we deal with Calibre Insurance (for instance an agent, broker or financial advisor); Claims assessment participants (for instance an assessor, investigator and/or loss adjuster); Other reputable service providers (for instance mail houses); and Underwriters, who are responsible for part/all of the risk under a contract of insurance (for instance a reinsurer). I/We authorise Calibre Insurance and/or GLA to give to or obtain from other insurers and/or an insurance or credit reference bureau information from this Application (including sensitive information), information from other insurances held by me/us with Calibre Insurance or GLA, and claims information obtained through the course of the contract. By signing this Application, I/we consent to Calibre Insurance and GLA collecting and using this information for these purposes. This is subject to my/our right to opt out of receiving various marketing materials at any time. I/We understand that this insurance does not operate until Calibre Insurance issues the Policy Schedule (except for any cover provided under an interim contract of insurance). Applicant s Signature Date / / Applicant s Title Calibre Commercial Insurance Pty Ltd Level 8, 1 Pacific Highway North Sydney, NSW 2060 Phone , Fax Calibre Commercial Insurance Pty Ltd