On-line Combined Liability Insurance


Thank you for considering our on-line combined 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 liability 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.


Indemnity Limit
1a. Please state the limit of indemnity required:
Broadform Liability $ Deductible $
Directors and Officers $ Deductible $
Professional Services $ Deductible $
Employment Practices Liability $ Deductible $
Estimated Payroll, turnover and financial position
2a. Estimated Annual Payroll (including earning of principals, director, partners)
Total Payroll
$ No.of Staff
2b. Estimated Annual Turnover $
2c. Please provide turnover percentage split by state
NSW  VIC  QLD  SA  WA  TAS  NT  ACT  O/S
%  %  %  %  %  %  %  %  %
Coverage for PRODUCTS EXPORTED TO USA OR CANADA is excluded from this insurance. Coverage will be provided only if specifically agreed by the Insurer.
Please complete the following table in respect of the Applicant and its controlled entities
3. Please advise your most recent financial year end
Most Recent Financial Year End $ Previous Financial Year End $
Current Assets $ $
Current Liabilities $ $
Total Assets $ $
Total Liabilities $ $
Intangibles $ $
Net profit/Loss (after tax) $ $
Financial Declaration
4a. Has there been any adverse effect on the financial position of the Application which is not reflected in your most recent financial year as set out in the above table or within any submitted financial statements?
Yes No
If "Yes", please provide details:
4b. Is any proposed Insured aware of any facts or circumstances that might effect the ability of the Applicant to meets its debts as and when they fall due?
Yes No
If "Yes", please provide details:
4c. Over the last 2 financial years have the financial statements of the Application been subject to a qualified audit report?
Yes No
If "Yes", please provide details:
5a. Do you employ contractors or subcontractors?
Yes No
If yes, please complete 5b. 5c. 5d. 5e. & 5f. below:
5b. Estimated annual payment: $
5c. Estimated annual payment for Labour Hire: $
5d. Nature of work usually carried out:
5e. Precautions taken to identify the adequacy of their liability and workers compensation insurance arrangements:
5f. Do you insist on being named as principals on contractors' and/or sub-contractors' liability policies?
Yes No
6. Please provide a breakdown of the professional services which the Applicant provides and the fees generated or the estimated percentage of turnover which relates to that professional service
Details of the business/premises
7. Please state the full details of your business operations (including subsidiary companies) including design, formulation, manufacturer, distribution, servicing, welding and other hot work. Please attach product brochures and details of all products for which cover is required.
8. Do you have representation outside Australia?
Yes No
If "Yes", where and what is the nature of your representation in such country (e.g. domicile employee, power of attorney, branch subsidiary, agency, etc.)?
9. Number of years in this business  years
10. Location of Premises owned and/or occupied for the purpose of conducting the business
Owned Leased
(i)
(ii)
(iii)
(iv)
11. Do you, or does anyone on your behalf, operate, manage, own or offer or in any way are connected with Railways e.g. sidings?
Yes No
If "Yes", please supply details
12. Do you, or does someone on your behalf, perform any work away from the premises stated above?
Yes No
If "Yes", please supply details e.g. welding, installation, servicing, repair, etc
13. Do you store, transport use or handle any hazardous goods e.g. chemicals, radioactive materials, gases, etc?
Yes No
If "Yes", please supply details
14. Does your operation/business create trade waste?
Yes No
If "Yes", please supply details e.g. type of waste, how it is disposed of, etc
Care Custody and Control
Coverage is provided for property in your physical or legal control, subject to a maximum indemnity of $50,000 for any one occurrence and in the aggregate for any one period of insurance.
15a. Do you require an amount in addition to the above limit?
Yes No
If "Yes", please answer questions 15b. to 15d.
15b. What limit of indemnity do you require? $
15c. Provide brief details of the property
15d. Is the property insured under any other policy
Yes No
If "Yes", please supply details
Product Information
16. Can you, with certainty identify the source of every item used in the manufacture of the products?
Yes No
If "No", please supply reason
17. Is your product range relatively stable or changing frequently?
Yes No
If "Yes", please supply details
18. Do you have quality control/risk management procedures in place?
Yes No
If "Yes", please supply details
19. Are your products subject to any Australian or international standard?
Yes No
If "Yes", please supply details
20. Do you have recall procedures in place?
Yes No
If "Yes", please supply details
21. Have you discontinued manufacturing, processing or handling any products?
Yes No
If "Yes", provide full details of reason, type of product, year, etc
22. Are any products specifically designed, manufactured, imported or handled for use in aircraft or other aerial devices or water craft?
Yes No
If "Yes", please supply details
Details of Board of Directors
23. Particulars of Directors:
Name of Director Qualifications Age Date Appointed
General Information
24. Has the Applicant had any insurance declined or cancelled, application rejected, renewal refused, claim rejected, special conditions or special excess imposed by an insurer?
Yes No
If "Yes", please supply details
Claims History - Public, Products and Advertising Liability
25. Has the Applicant had any claims made against you (whether insured or not) or have you recalled any of your products during the last 7 years?
Yes No
If "Yes", please supply details
Claims History - Directors & Officers and Trustees
PLEASE NOTE: We do not require disclosure in this question of any claim or circumstance relating to a potential or actual employment practices dispute(s)
26a. Has there been, or is there now pending, any claim against any Applicant in their capacity as a director, officer or Trustee of either the Applicant or any other company, organisation, association, or trust?
Yes No
If "Yes", please supply details
26b. Do any circumstances exist that might give rise to a claim against any Applicant?
Yes No
If "Yes", please supply details
Claims History - Applicant
PLEASE NOTE: We do not require disclosure in this question of any:
  • Claim or circumstance relating to a potential or actual employment practices dispute(s)
  • Any claim or circumstance against the Applicant which is covered under a public liability, products liability or workers compensation insurance policy arranged by or to benefit of the Applicant
  • Any claim or circumstance against the Applicant alleging a breach of professional duty (including an allegation of professional negligence)
27a. Has there been, or is there now pending, any claim against the Applicant, including any action litigation or other proceeding brought under or pursuant to any Commonwealth, State, or Territory legislation?
Yes No
If "Yes", please supply details
27b. Has there been, or is there now pending, any investigation, examination, inquiry or other proceedings in relation to the affairs of the Applicant?
Yes No
If "Yes", please supply details
27c. Do any circumstances exist that might give rise to any event described under 27a. or 27b. above?
Yes No
If "Yes", please supply details
Claims History - Employment Practices Liability
28a. Has there been, or is there now pending, any employment practices claim against any Applicant, including but not limited to any claim alleging unlawful discrimination, defamation, unlawful dismissal, invasion of privacy, or harassment?
Yes No
If "Yes", please supply details
28b. Has there been, or is there now pending, any employment practices claim against any Applicant, including any claim alleging unlawful discrimination, defamation, unlawful dismissal, invasion of privacy, or harassment?
Yes No
If "Yes", please supply details
28c. Do any circumstances exist that might give rise to an employment practices claim against any Applicant?
Yes No
If "Yes", please supply details
28d. Has the Applicant had any office closures, consolidations, mergers or acquisitions in the past 3 years resulting in any lay-offs or early retirement, or are any such closures, consolidations, mergers or acquisitions anticipated in the next 12 months?
Yes No
If "Yes", please supply details
Claims History - Professional Services
29a. Has any Applicant ever been subject to disciplinary proceedings for professional misconduct?
Yes No
If "Yes", please supply details
29b. Have any claims for professional negligence or breach of professional duty been made in the last 10 years against any Applicant or any of their predecessors in business or any prior business of any of their present of former directors, partners, or principals?
Yes No
If "Yes", please supply details
29c. Do any circumstances exist that might give rise to a claim against a Applicant for professional negligence or breach of professional duty?
Yes No
If "Yes", please supply details
Merger, Acquisition or Takeover Activity
30a. Has the Applicant been involved in any merger, acquisition, takeover or divesture in the last 3 years?
Yes No
If "Yes", please supply details
30b. Is the Applicant considering any acquisition, takeover or divesture proposal at present?
Yes No
If "Yes", please supply details
30c. Is the Applicant subject to any takeover attempt, or has there been any attempted takeover of the Applicant in the past 3 years?
Yes No
If "Yes", please supply details
Risk History - Employment Practices
31a. Has the Applicant's employment policies and procedures been reviewed and approved by external legal counsel?
Yes No
If "Yes", please supply details
31b. Is there a complaints handling procedure in place to address workplace grievances?
Yes No
If "Yes", please supply details
31c. Is there a policy prohibiting inappropriate use of computer technology such as e-mail, screen savers, etc?
Yes No
If "Yes", please supply details
31d. Does the Applicant distribute any employment handbook to employees?
Yes No
If "Yes", please supply details
Insurance Cover - Directors & Officers
32. Does the Applicant presently carry, or has the Applicant ever carried Directors & Officers Liability Insurance?
Yes No
If yes, please provide details below:
Expiry date:
Insurance company:
Indemnity limit: $
Excess: $
Premium: $
Insurance Cover - Professional Services
33. Does the Applicant presently carry, or has the Applicant ever carried, Professional Services Liability Insurance?
Yes No
If yes, please provide details below:
Expiry date:
Insurance company:
Indemnity limit: $
Excess: $
Premium: $
Insurance Cover - Employment Practices
34. Does the Applicant presently carry, or has the Applicant ever carried, Employment Practices Liability Insurance?
Yes No
If yes, please provide details below:
Expiry date:
Insurance company:
Indemnity limit: $
Excess: $
Premium: $
Application For Cover
Please indicate any Optional Extension for which you seek cover
35a. Increased Aggregate Limit of Liability (Reinstatement)
Yes No
35b. Outside Directorship (Blanket and Run-off Cover)
Yes No
35c. Extended Reporting Period
Yes No
35d. Solvency Protection
Yes No
If you have answered Yes to 35d. please copy & paste or email the last 2 Annual Reports and financial statements (including audit report) of the Applicant
35e. PLEASE NOTE
(a) If cover is requested for any Optional Extension, then the Insurer may require additional information and reserves the right to change any additional premiums as it may require or refuse to provide cover.
(b) If cover is required for the Outside Directorship Extension, please supply full details of all Outside Directorships, including the name of the Outside Entity and details of any Directors and Officers Insurance held by the Outside Entity. Please note that is not necessary to submit Annual Reports or financial statements for any Outside Entity unless requested by the Insurer.
  Details of D&O Insurance
Outside Entity Insurer Limit Deductible/Excess Expiry Date
Contractual Liability
Coverage for liability assumed under agreement or contract will be limited to lease liability or liability assumed under a warranty of fitness or quality as regards your products, or specifically agreed contracts.
36. Do you assume liability under contract or hold others harmless (other than lease liability)?
Yes No
If "Yes", please provide details and attach copies of all agreements (other than lease liability). Coverage under Section 1 will be provided only if specifically agreed by the Insurer.


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.
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ABN:
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