Business Insurance - Australia Wide. SME and Public Liability Cover - Insurance Brokers Sydney Melbourne Brisbane Adelaide Perth Hobart - Market Stall Insurance

General Public & Product Liability

NEW ZEALAND NATIONWIDE INSURANCE BROKER SERVICES
Auckland • Wellington • Christchurch • Dunedin • Queenstown • Gisborne

GENERAL PUBLIC LIABILITY & PRODUCT LIABLITY INSURANCE

NEEDS ANALYSIS FORM

Terms and Conditions

GENERAL DETAILS

Section 1

Please tell us the reason you require public liability insurance

Have you or anyone associated with your business ever made a claim under this type of insurance?		Yes No

Details of Claims and Amounts Paid

Suburb where the risk you are insuring
is located

State

Postcode

If you require cover for more than the limitations above please contact us

What is the Expiry Date of your current insurance - or What date would you like a Quote from?		DD / MM / YYYY

PUBLIC LIABILITY INSURANCE ONLY -

Section 2

Public Liability:-

YOU MUST SELECT THE LEVEL OF COVER YOU REQUIRE
ie; $5 million or $10 million or $20 million

No. of Employees or Volunteers:-

YOU MUST SELECT THE NUMBER OF EMPLOYEES AND/OR VOLUNTEERS WHO WORK FOR YOU EVEN IF YOU ARE A SOLE TRADER YOU MUST SELECT "SOLE TRADER"

Is there any toxic substances produced in your business and/or activity for which this insurance is required?		Yes No
If Yes, does your waste disposal or waste storage comply with Government Regulations and By-Laws?		Yes No

If Yes to any of the two questions above, please provide details about the type of toxic substances produced and the waste disposal or waste storage processes.

IF PUBLIC LIABILITY IS ALL YOU REQUIRE PLEASE

TO TAKE YOU TO 'SECTION 4

PRODUCT LIABILITY INSURANCE ONLY

Section 3

You do not need to complete this section if all you want is Public Liability Insurance -

Do any of the Products that you wish to insure relate to or contain any of the following:

Aircraft (including component parts)	Yes No	Pesticides	Yes No
Ethical Drugs	Yes No	Fungicides	Yes No
Industrial Chemicals	Yes No	Liquid or Gas Fuel	Yes No
Petrochemicals	Yes No	Watercraft	Yes No
Class 1 Dangerous Goods	Yes No	Radioactive Materials	Yes No
Fertilisers	Yes No	Asbestos	Yes No


Please tell us about the Types of Products you want to insure

INSURED VALUES

What is the maximum retail price of the single most expensive product you wish to ensure:-

Important:- Determining an insured value is never easy but it is extremely important. It may be necessary to arrange a valuation and we can help you with that or your accountant might be able to tell you the value.

DISCLOSURE AND ACKLOWLEDGEMENT DETAILS -

Section 4

Please examine your Duty of Disclosure

Have you or any person associated with this activity ever:-

had a Legal Liability claim made upon you or the other person?

ever made a claim for insurance in respect of the type of cover you require?

been refused insurance?

had an insurance claim of any type refused or reduced?

been charged with a crime of any type?

Is there anything else you
need to disclose to us?

If yes, please write here what it
is that you think we ought to know

I acknowledge I have read and I agree to the terms and conditions stated. (Tick box)

Your Answer is Mandatory

YOUR INFORMATION -

Section 5

First name
Last name
Business name
Address of where your Business is situated [Include Postcode and State]
Postal address if different from above [Include Postcode and State]
Business Telephone [Include Area Code]
Facsimile [Include Area Code]
Mobile
Email Address
Do you have any other comments/requirements?

RGIB is an Insurance Broker, we work for you so the more information you give us helps us to arrange a better insurance deal for you. We will not use your information for any other purpose or provide it to anyone else.

Are you Currently Insured? Yes No

Which company?

Other

It is helpful to know who your current insurer is so we do not approach that insurer again

If you just want the Cheapest and Best Deal click here

Thank you we will do our best to respond in the next few hours - but we may need to contact you for further information

Rural & General Insurance Broking P/L [RGIB] is an Australian licensed Insurance Brokerage [AFSL 262-353]