Additional Contractor Liability Proposal Form (Page 3 of 4) in pdf

Additional Contractor Liability Proposal Form Page 3

3. DETAILS OF THE PROPOSED CONTRACTOR/SUBCONTRACTOR

(Note: Must be completed by the Proposed Contractor/Subcontractor, and NOT the existing Insured)

Company or Individual Name

A.B.N.

I.T.C.%

Please state the number of years:

In continuous business:

______ years

Experience in your field:

______ years

Will you be working exclusively for the Insured?

YES / NO

If “YES”, please state the name of the entity which has engaged your services.

Is there a written contract between you & the Insured?

YES / NO

Do you assume liability under contract or hold others harmless (other than lease liability)?

YES / NO

If “YES”, please provide full details and attach copies of all applicable agreements (other than leases).

Do you manufacture, import, export, re-package &/or distribute any product?

YES / NO

If “YES”, please detail:

Do you engage any contractors/sub-contractors?

YES / NO

4. ESTIMATED PAYROLL & TURNOVER OF THE PROPOSED CONTRACTOR/SUBCONTRACTOR

Please state your gross annual turnover:

Please state your estimated annual payroll including the remuneration of Principals, Directors, & Partners

Payroll

Staff Numbers

Management, Clerical and Sales

Manufacturing

Work away from your premises

Other (please specify)

Total

5. CLAIMS AND/OR LOSS EXPERIENCE OF THE PROPOSED CONTRACTOR/SUBCONTRACTOR

After investigation, are there any circumstances for which you in the past 7 years:

Were fined or required to pay a penalty?

YES / NO

ii.

Could be required to pay a fine or penalty?

YES / NO

If “YES”, please provide full details.

Prop PL Contractor-Subcontractor - 2013-08-01

Page 3 of 4

Additional Contractor Liability Proposal Form Page 3