On-line Mine Supervisors Public and Products Liability Insurance


Thank you for considering our on-line mine supervisors 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 mine supervisors 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. Full Description of Occupation:
4. Area of Operation:
5. Number of years in this business under this name:
6. Previous industry experience if less than five years in business:
7. Are you represented outside Australia?
Yes No
If Yes, please provide details:
8. Details of all claims or incidents in the past 5 years (incl. Contributing deductibles):
9. Existing deductible: $
10. Estimated annual Turnover: $
11. Estimated annual wages: $
12. Are Labour Hire Employees engaged by or on behalf of 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:
13. Are Contractors or Sub Contractors engaged by or on behalf of the Insured?
Yes No
If Yes, please advise estimated turnover and wages relating to the contracts and the activities performed by such persons:
14. 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:
15. What work is performed away from your premises by you or on your behalf? Please provide details of such work, including types of sites worked on and an estimated % of turnover derived.
16. Do you agree to indemnify or hold harmless any other parties, by written agreement or otherwise?
Yes No
17. Limit of Indemnity: $
18. Please provide details of any training provided, with particular comment on any training involving physical activity participation by trainees:
19. Does the Insured carry Professional Indemnity Insurance?
Yes No
20. Names of mines usually worked at:
21. What substance(s) is/are mined?
22. What work is performed underground?
23. What % of work is performed underground? %
24. To what maximum depth is work performed underground?
25. Does the Insured's work involve the use of Plant/Machinery?
Yes No
If Yes, for what purposes?
26a. Does the Insured supervise blasting activities?
Yes No
If Yes, please advise full details of:
26b. Minimum distance to third party property:
26c. Site safety procedures:
26d. Explosive storage details:
26e. Audit/Inventory procedures:
26f. Who performs blasting:
26g. Are they appropriately licensed:
27a. What explosives are used?
27b. How often does blasting occur?
27c. What is the maximum charge per hole?
27d. What is the maximum number of holes per blast?
28. Does the Insured supervise the use, control or clearing of tailings ponds?
Yes No
If Yes, please provide full details of anti pollution safeguards, distance to the local water table and distance from the nearest water course:
29. Are all operations undertaken in line with relevant Australian Mining Standards?
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: