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Limit of Liability Required * 🛈

Company, Business or Trading Name * 🛈

ABN Click here for ABN Look Up

Postcode *

Occupation * 🛈

Please Describe Your Business Activities *

Number of Staff Including Directors *

Estimated Annual Turnover * 🛈

Estimated Amount Paid to Sub-Contractors 🛈

Gender

Height

Weight

Age at next birthday

Are you a Smoker?

Contact Details

First Name

Last Name *

Phone *

Email *

Are you aware of any matters not disclosed above that is relevant to the underwriters consideration of this insurance.

Ever been declared bankrupt?
Ever been involved in a company or business which became insolvent or subject to any form of insolvency or voluntary administration (e.g. liquidation or receivership)?
Ever been convicted of any criminal offence (other than minor traffic convictions)?
In the past 5 years has the business had any public liability claims, or any circumstances that could give rise to a claim in the future?
*

If "Yes" please give details also supply details for underwriters consideration & Comments

Declaration: I/WE HEREBY DECLARE AND WARRANT that the answers given above are in every respect true and correct, and that I/We have not withheld any information within My/Our knowledge likely to affect the decision of the Company as to My/Our eligibility for insurance. This request and declaration shall be the basis of the quote request. *

Publicliabilitycomparison.com.au by Insure 247 Ausure Insurance Brokers Pty Ltd T/as Insure 247 Authorised Representative of Ausure Pty Ltd AFSL 238433.