PROPOSAL FOR EMPLOYERS LIABILITY INSURANCE
No risk attaches until the proposal has been accepted by the company and premium is paid or agreed to be paid
Your Details
Business name:
Business’s Physical Address:
Type of Business:
Contact details:
Postal Address:
Telephone
Work:
Home:
Mobile:
E mail:
YOUR DUTY OF DISCLOSURE
You must tell us everything you know (or could be reasonably expected to know) that a prudent insurer would want to take into account in deciding:
Whether to accept your proposal, and
If so, on what terms.
Examples of what you must tell us include:
Anything that increases the risk of a claim
Any criminal offending or convictions
Any previous insurance claims
Any refusal by another insurer to insure you on standard terms, or continue to insure
You on standard terms. You must also tell us this every time this policy renews, and when you make any changes to it. If you fail to do this, we may avoid the policy back to when it started as if you were never insured at all.
When in doubt, disclose. We treat all information confidentially
Your Privacy
We collect and receive your personal information in this proposal to decide whether to insure you. We hold it. You have rights to access it, and correct it under the Privacy Act 1993.
You must supply your personal information to us if it comes within your duty of disclosure (see Your Duty of Disclosure above). If you fail to do so, we may decline your proposal or avoid your insurance retrospectively.
We obtain your authority below to transfer some or all of it to other members of the insurance industry, financially interested parties noted on your policy and Insurance Claims Register Limited.
YOUR PREVIOUS HISTORY
The following questions must be answered in relation to the business, and in relation to every director and manager of the business
Has any insurer ever refused to insure you on standard terms, or refused to renew your insurance on standard terms?
Yes
No
Has any insurer ever refused to pay your insurance claim?
Yes
No
Have you made any insurance claim in the last five years?
Yes
No
Do you know of any circumstances that could lead to a claim under any of our policies in the future?
Yes
No
Do you have any criminal convictions (including traffic offences, but not parking offences), or are you currently facing a prosecution?
Yes
No
If Yes, please list each offence or prosecution, and each sentence your business has received.
If you have answered yes to any of the above questions, please write full details below
BUSINESS DETAILS
What is the estimated business turnover?
Number of years since business established?
Estimated annual wages of business?
Number of employees?
Is any work done away from your business?
Yes
No
If Yes, please describe
Does your business involve dangerous operations (e.g. hazardous substances, use of naked or open heat sources, excavation of land)?
Yes
No
If Yes, please describe
Does your business operate outside New Zealand in any way
Yes
No
Please describe land on which your business is situated:
Does your business discharge dangerous or toxic substances?
Yes
No
Do you store other people's property at your business?
Yes
No
If Yes, please state type, value and location of those items.
Has your business ever been investigated, issued with an official notice prosecuted or sued under the:
Build Act
Yes
No
Health and Safety in Employment Act
Yes
No
If you have answered Yes to any of these above questions, please write full details below
OPTIONAL LIABILITY COVER
Do you require the Exemplary Damages in NZ extension?
Yes
No
SUMS INSURED:
Legal Liability ($)
YOUR DECLARATION
I declare that I:
Have answered all questions truthfully
2 Have, in addition, disclosed all material facts to New India (please see Your Duty of Disclosure above)
3 Agree to the policy terms and conditions.
4 Authorize:
4.1 New India to advise me of its other services from time to time
4.2 The disclosure of my personal information held by New India to other members of the insurance industry, financially interested parties noted on the policy and Insurance Claims Register Limited.
4.3 The disclosure of my personal information held by other members of the insurance industry and Insurance Claims Register Limited to New India for the purpose of considering this proposal and administering the policy.
5 Am authorized to complete this proposal on behalf of anyone else to be insured under the policy, and agree that they give the same declarations.