On-line Public and Products Liability Insurance


Thank you for considering our on-line public and products liability insurance service.   Because Greater National Group is an insurance broker, not an insurance company, we will process your application with major insurance companies in order to find the right public and products liability insurance for you.

Please fill in the following form as fully as possible, then click 'submit' at the end of the form.
You can use the TAB key to move to the next field. We will respond with your terms as soon as we have researched the market for the right available deals that fit your requirements.


Limit of Liability Required:
1a. Please select the the amount of Liability cover required:
$5,000,000 $10,000,000 $15,000,000 $20,000,000
1b.
Public Liability (any one occurrence)
Products Liability (each Period of Insurance)
2. Do you currently have Public Liability insurance?
No Yes
If Yes, please provide details below:
Expiry Date
Insurance Company
Indemnity limit $
Excess $
Premium $
Company Details:
3a. Type of Business/Occupations
3b. Fully describe your business activities in detail:
How many years operating:
3c. This business? Years
3d. Other business? Years
3e. Postcodes of branch office/depots/operating bases:
3f. Has any Insurer ever declined or refused to renew or canceled or imposed special terms of conditions to any proposed insurance by You?
No Yes
If Yes, please give details:
3g. Please provide details of all claims made against You or incidents reported to You that may give rise to a claim:
Financial Information:
4a. What is your estimated annual revenue turnover? $
4b. What is your annual payment to subcontractors? $
4c. What is estimated annual payroll including earnings of principals, directors, partners? $
Role Payroll No. of Staff
Managerial, Clerical and Sales
Manufacturing
Installation
Other
Total


Duty of Disclosure:
Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?
Yes No
If so, please provide details:
I/We hereby declare that:
My/Our attention has been drawn to the Important Notices accompanying this form and further I/we have read these notices carefully and acknowledge my/our understanding of their content. The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this form and the inception date of the insurance to which this relates I/we shall give immediate notice thereof. I/We authorise GNG and the Insurer to collect or disclose any personal information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact and the Privacy Policy. I/We also confirm that I/we am/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this form and I/we complete this form on their behalf.
Any other comments, requests or relevant information you need to add:
Contacting you about your quote:
In order to select the most appropriate cover for you, it may be important to discuss quote details in person. Please leave a contact phone number and best time to call to facilitate this.
Your full name:
Company/Business/Name of Applicant to be Insured:
ABN:
Your phone number (please include area code):
Your mobile phone number:
Best time(s) to call:
Please send my quote by (select at least one):
email phone fax mail
Your email address:
Your website address:
Your fax number:
Your postal address:
Country: