On-line Scaffolders Public and Products Liability Insurance

Thank you for considering our on-line scaffolders 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 scaffolders 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
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. What is the estimated maximum height, in storeys and metres, worked to by the Insured?
5. What is the estimated maximum value of any one contract? $
6. Area of Operation:
7. Number of years in this business under this name:
8. Previous industry experience if less than five years in business:
9. Split of turnover/revenue:
Hire of scaffold: %
Hire of other items (please describe): %
Erection/dismantling: %
Manufacture: %
Maintenance/repair: %
Sales (new): %
Sales (second hand): %
Delivery: %
Other activities (please list): %
10. Details of all claims or incidents in the past 5 years (incl. Contributing deductibles):
11. Existing deductible: $
12. Estimated annual Turnover: $
13. Estimated annual wages:
Field Contractors: $
Office/Management Staff: $
Other (Please specify): $
14. 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:
15. Are Contractors or Sub Contractors engaged by the Insured?
Yes No
If Yes, please advise estimated turnover and wages relating to the contracts and the activities performed by such persons:
16. Split of height worked to:
Under 2 storeys: %
From 2-5 storeys: %
From 5-10 storeys: %
Over 10 storeys: %
17. Split of type of work:
Domestic below 2 storey: %
Domestic exceeding 2 storey: %
Commercial (non CBD): %
CBD: %
18. Do you agree to indemnify or hold harmless any other parties, by written agreement or otherwise?
Yes No
19. Limit of Indemnity: $
20. Does the Insured operate to relevant Australian Standards for the industry involved?
Yes No
If Not, what risk management procedures are in place?
21. Is there a documented inspection procedure in place, both prior to and post hire?
Yes No
22. Are written instructions provided to ensure safe use and maintenance of equipment?
Yes No
23. Is there a formal training process in place for staff?
Yes No
24. Please advise details of any mobile plant or machinery used by the Insured:
25. Have you, or anyone in your employ, ever been charged with breach of the relevant Occupational Health and Safety regulations governing this industry?
Yes No
If Yes, please detail:
26. Does the Insured perform any hot work duties?
Yes No
If Yes, please describe and confirm if a "Hot Work" permit system is used:
27. Is any work performed on the following sites:
% of turnover derived from work on site
Underground sites
Air or Watercraft
Oil or gas production facilities
Chemical works
Security sensitive sites
If any of the sites have been selected, please provide a full description of work performed:

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:
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: