LICENSED BUILDERS – ANNUAL INSURANCE COVER FORM LICENSED BUILDERS – ANNUAL INSURANCE COVER Please select the term of cover you are applying for, from the tabs below BUSINESS DETAILS Contact Person Business Entity Name Contractors License Number Phone Email Address Street Address Suburb State —Please choose an option—ACTNSWQLDVICNTSAWATAS Postcode INSURANCE DETAILS Public Liability Select$10 Million$20 Million Annual Turnover Policy Excess (higher excess reduces annual premium) $1,000$2,500$5,000 Policy Start Date Description of business activity (select one): Select one option belowRegistered builder undertaking residential construction including new and alterations onlyRegistered builder undertaking commercial construction including new and alterations onlyRegistered builder undertaking both residential and commercial including new and alterations onlyRegistered builder undertaking industrial work Civil contractorsOther (including incidental activities not catered for within the above descriptions) UNDERWRITING QUESTIONS Have you (in the past five (5) years): 1. Made 2 or more claims on an insurance policy for loss or damage in the past three (3) years or any claims in excess of $10,000 either individually or cumulatively in the past five (5) years? YesNo 2. Had any insurance declined or cancelled, application rejected, renewal refused, claim rejected, special conditions or excess imposed by an insurer? YesNo 3. Suffered any loss or damage which would have been covered by the proposed insurance policy greater than $50,000 either individually or cumulatively? YesNo Have you or any partner(s), shareholder(s) or director(s) of the business: 4. Ever been declared bankrupt, insolvent or placed into administration? YesNo 5. Been convicted of any criminal offence? YesNo Do you undertake or assume responsibility for any of the following: 6. Projects Valued Over $5,000,000 YesNo 7. Civil works and/or earth works not associated with a total building contract (incl road or sub-divisions) exceeding $50,000? YesNo 8. Excavation more than 5 metres in depth or contracts involving works at height of greater than 5 stories YesNo 9. Works on, in, over or under Water YesNo 10. Work involving Special Hazards (eg: Blasting or work around petroleum, steel or heavy industries such as automobile manufacturing facilities, mining, petroleum, chemical or steel industries, paper production, power generation, stone, mineral, oil, gas or metal extraction or production, printing or explosive atmosphere processes, tunnelling, micro tunnelling, pipe-jacking, and directional drilling) YesNo 11. Work taking place on, in or around aircraft or watercraft YesNo 12. Work with Asbestos YesNo 13. Work involving piling, shoring greater than 1m in height or underpinning YesNo 14. Work to Heritage Buildings YesNo 15. Work involving house raising, restumping or relocating YesNo 16. General Liability for vacant land of more than 2 lots YesNo 17. Where responsibility is assumed from another builder after commencement of works YesNo 18. Product imports / re branding / re packaging YesNo 19. Erection of machinery or plant (EAR Risks) unless the component is part of residential or commercial building construction and is less than 20% of the total contract value YesNo 20. Demolition Works other than work incidental to the main contract and involving stand alone structures on the contract site not exceeding 10 metres in height YesNo 21. Business activities as a Labour Hire company YesNo 22. Works involving prototype or experimental materials or construction methods YesNo 23. Work involving Educational Institutions, Medical complexes and Shopping centres YesNo 24. Work outside of mainland Australia and Tasmania YesNo 25. Work involving swimming pool only contracts, landscaping only contracts or waterproofing only contracts? YesNo Provide any additional information that may assist with your application General Advice I confirm that I have read the Financial Services Guide and understand that BuildInsure have not taken into account my/our individual objectives, financial situations or needs. Declaration I declare that I have read and understood the duty of disclosure notice contained in the Important Notices and the statement and particulars in this proposal form are true and that no material facts have been misstated or suppressed after enquiry. I further agree that should any of the information given by me alter between the date of the proposal and the inception date of the insurance to which this proposal relates, I will give immediate notice to BuildInsure. I consent to the use and disclosure of my personal information (and that of any other persons to whom this application relates) in accordance with the "Privacy Statement" contained in the Important Notices. I agree that this proposal, together with any other information supplied by me shall form the basis of any contract of insurance effected thereon. Click here - to view the Financial Services Guide Click here to view the Privacy Statement. I have read and agree to the above declaration.