On-line Chemical Importer/Manufacturer Public and Products Liability Insurance


Thank you for considering our on-line chemical importer/manufacturer 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 chemical importer/manufacturer 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 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?
Yes No
If Yes, please provide details below:
Expiry Date
Insurance Company
Indemnity limit $
Excess $
Premium $
Business Details:
3. Description of Occupation:
4. Situation of risk:
5. Number of years in this business under this name:
6. Previous industry experience if less than five years in business:
7. Details of all claims or incidents in the past 5 years (incl. Contributing deductibles):
8. Existing deductible: $
9. Estimated annual Turnover: $
10. Estimated annual wages: $
11. Are Labour Hire Employees engaged by the Insured under a Contract of Service?
Yes No
If Yes, please advise estimated turnover and wages relating to these contracts and the activities performed by such persons:
12. Are Contractors or Sub Contractors engaged by the Insured?
Yes No
If Yes, please advise estimated turnover and wages relating to these contracts and the activities performed by such persons:
13. Are any products or components imported or exported?
Yes No
If Yes, please provide details of turnover, percentage and countries imported from or exported to:
14. Do you ascertain that the overseas manufacturers or suppliers carry a minimum of $5,000,000 public and products liability insurance?
Yes No
15. Estimated percentage of payroll split between work at and away from your own premises:
Work at own premises: % No. of employees:
Work away from own premises: % No. of employees:
16. Is work performed away from your premises by you or on your behalf?
Yes No
If Yes, please provide details of such work, incl. type of sites worked on, and an estimated % of the turnover derived:
17. Do you agree to indemnify or hold harmless any other parties, by written agreement or otherwise?
Yes No
18. Provide full details of all products sold or manufactured (Attach brochures and product literature where available):
19. Are there any discontinued products not listed above?
Yes No
If Yes, please provide details:
20. Limit of Indemnity: $
21. Preferred Deductible: $
22. Number of premises owned:
23. Number of premises leased:
24. Value of leased premises: $
25. Are the premises purpose built for the nature of work undertaken?
Yes No
26. Are all chemical production areas bunded to 100% of capacity?
Yes No
If Not, to what extent are they bunded?
27. Do the premises have fully contained and controlled drainage systems installed?
Yes No
28. How old are the premises?
29. Does the Insured design product or operate a research and design facility?
Yes No
30. Is the Insured accredited to ISO or AS Standards?
Yes No
Please specify details of these or other professional standards worked to:
31. If not accredited, do they operate a Quality Control System?
Yes No
If Yes, please provide details incl. product testing, inspections and defect tolerances, if any:
32. Does the Insured perform packing, repacking or labelling of product not manufactured by them?
Yes No
33. What type of client forms the typical end user for the Insured?
34. Does the Insured have a Product Recall Programme in place?
Yes No


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: