Pen Underwriting Proposal Form (Page 4 of 4) in pdf

4.6. If you work in shopping centres during business hours, is CCTV footage available

of all work areas?

Yes

are you able to access it?

Yes

4.7. Do you have an existing OH&S system in place?

Yes

Is it externally audited?

Yes

4.8. Provide details of any agreements you have made under which you:

Accepted Liability which would not normally be your responsibility: ...............................................................

........................................................................................................................................................................

Given away your legal rights of recovery from other parties: ..........................................................................

........................................................................................................................................................................

Declaration:

I/We declare that:

I/We am authorised by each of the Applicant(s) to sign this Proposal

The statements in this Proposal are true and complete and no material information has been withheld

I/We have read and understood the Important Notices accompanying this Proposal

I/We have diligently made all necessary enquiries in order to comply with the duty of disclosure

I/We have read the Pen Underwriting Privacy Statement on this Proposal and consent to the use, disclosure and

obtaining of personal information about the insured for the purposes shown in the Privacy Statement

Where I/We have provided information about another individual, that individual has been made aware of that fact and

of the Pen Underwriting Privacy Statement

I/We acknowledge that Pen Underwriting relies on the information and representations in this Proposal and otherwise

made by me or on my behalf in relation to this insurance

Except where indicated to the contrary, I/We understand that any statement made in this Proposal will be treated as a

statement made by all persons to be insured

I/We undertake to notify Pen Underwriting of any material alteration to the information contained in this Proposal prior

to inception of the proposed insurance

I/We understand that no insurance is in place until such time as Pen Underwriting has confirmed acceptance of the

proposed insurance

Signature/s: ....................................................................................................................

Date: .........................................

Name/s: ...........................................................................................................................

Title: .........................................

Commercial Cleaners Proposal Form v11.14

Page 4 of 4

Pen Underwriting Proposal Form Page 4

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