On-line Voluntary Workers Insurance

Thank you for considering our on-line voluntary workers 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 voluntary workers 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 deal that fits your requirements.

1. Total number of Voluntary Workers:
2. Maximum number of Voluntary Workers on any one day:
3. Maximum number of days on which Voluntary Work is carried out:
4. Please indicate the nature of Voluntary Work performed:
Yes No
Canteen Duties
Yes No
Child Supervision
Yes No
Yes No
Building Projects
Yes No
If "Yes", estimate value of the project $  
Working Bees
Yes No
Yes No
Yes No
Yes No
Collection Days/Button Days
Yes No
If "Yes", specify no. of collectors    and no. of days  
Door Appeals
Yes No
If "Yes", specify no. of collectors    and no. of appeals  
Other (please describe in detail)
5. Have you had any insurance declined or cancelled, or had special terms imposed by an insurer?
Yes No
If yes, please provide details:
6. Have you ever claimed on this Class of Insurance during the last 5 years?
Yes No
If yes, please provide details:
Benefits Selected
Section A - Capital Benefits
7. Benefit Amount: $

Section B - Weekly Benefits - Injury
8. Weekly Benefit: $
9. Benefit Period:  weeks
10. Excluded period of claim:  days

Section D - Injury Assistance Benefits
11. 75% Non Medical Related Expenses: $
12. 75% Home Tutorial Expenses:  weeks
Benefit Period 26 weeks
13. Deductible: $

Aggregate Limit Of Liability
14. Sections A, B, & D $
15. Chartered Aircraft $
16. Light Aircraft $
17. Helicopter $

Time of Operation of Cover
18. Engaged in Voluntary Work
Yes No
19. Travel to and from such Voluntary work
Yes No
20. Other
Yes No
If yes, please provide details:

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: