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Form name:

<div class="rounderCornerMiddle">
        <div id="wrapper">
            <div class="headerText">
                PROPOSAL FOR CARRIER’S LIABILITY INSURANCE                
            </div>
            <div>
            <strong>
                    No risk attaches until the proposal has been accepted by the company and premium is paid or agreed to be paid</strong>                    
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            <fieldset>
                <legend>YOUR DETAILS </legend>
                <div class="itemField">
                    <div class="listDiv2">
                        Business Name: </div>
                    <div class="listDiv">
                        <input type="text" name="txbBussinessName" /></div>
                </div>
                <div class="itemField">
                    <div class="listDiv2">
                        Business Physical Address: </div>
                    <div class="listDiv">
                        <textarea name="txbBussinessPhysicalAddress" cols="22" rows="5"></textarea></div>
                </div>
                <div class="itemField">
                    <div class="listDiv2">
                        Type of business</div>
                    <div class="listDiv">
                        <input type="text" name="txbBussinessType" /></div>
                </div>
                <div class="itemField">
                    <span class="blueBolderText">Contact Details</span></div>
                <div class="itemField">
                    <div class="listDiv2">
                        Postal Address: </div>
                    <div class="listDiv">
                        <textarea name="txbPostalAddress" cols="22" rows="5"></textarea></div>
                </div>
                <div class="itemField">
                    <span class="blueBolderText">Telephone</span></div>
                <div class="itemField">
                    <div class="listDiv2">
                        Work: </div>
                    <div class="listDiv">
                        <input type="text" name="txbWork" /></div>
                </div>
                <div class="itemField">
                    <div class="listDiv2">
                        Home: </div>
                    <div class="listDiv">
                        <input type="text" name="txbHome" /></div>
                </div>
                <div class="itemField">
                    <div class="listDiv2">
                        Mobile: </div>
                    <div class="listDiv">
                        <input type="text" name="txbMobile" /></div>
                </div>
                <div class="itemField">
                    <div class="listDiv2">
                        Email: </div>
                    <div class="listDiv">
                        <input type="text" name="txbEmail" /></div>
                </div>
            </fieldset>
            <fieldset>
                <legend>your duty of disclosures</legend>
                <div class="itemField">
                    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: </div>
                <div class="itemField">
                    <ul>
                        <li>whether to accept your proposal, and</li>
                        <li>if so, on what terms.</li>
                        <li>Examples of what you must tell us include:  anything that increases the risk of a claim</li>
                        <li>any criminal offending or convictions
                            <br />
                            Any previous insurance claims 114791312 \ 0375440 \ CRG01</li>
                        <li>any refusal by another insurer to insure you on standard terms, or continue to insure you on standard terms.</li>
                        <li>You must also tell us this every time this policy renews, and when you make any changes to it.</li>
                        <li>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. </li>
                    </ul>
                </div>
            </fieldset>
            <fieldset>
                <legend>Your Privacy </legend>
                <div class="itemField">
                    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. <br />
                    <br />
                    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.
                    <br />
                    <br />
                    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.</div>
            </fieldset>
            <fieldset>
                <legend>Your Previous History </legend>
                <div class="itemField">
                    The following questions must be answered in relation to the business, and in relation to every director and manager of the business Please circle</div>
                <div class="checkboxItemField">
                    <label>Has any insurer ever refused to insure you on standard terms, or refused to renew your insurance on standard terms?</label>
                        <input type="radio" name="rbtnInsurer" value="Yes" />
                        <input type="radio" name="rbtnInsurer" value="No" />
                </div>
                <div class="checkboxItemField">
                    <label>Has any insurer ever refused to pay your insurance claim?</label>
                        <input type="radio" name="rbtnInsurenceClaim" value="Yes" />
                        <input type="radio" name="rbtnInsurenceClaim" value="No" />
                </div>
                <div class="checkboxItemField">
                    <label>Have you made any insurance claim in the last five years?</label>
                        <input type="radio" name="rbtnInsurenceinFiveYears" value="Yes" />
                        <input type="radio" name="rbtnInsurenceinFiveYears" value="No" />
                </div>
                <div class="checkboxItemField">
                    <label>Do you know of any circumstances that could lead to a claim under any of our policies in the future?</label>
                        <input type="radio" name="rbtnCircumstances" value="Yes" />
                        <input type="radio" name="rbtnCircumstances" value="No" />
                </div>
                <div class="checkboxItemField">
                    <label>Do you have any criminal convictions (including traffic offences, but not parking offences), or are you currently facing a prosecution?</label>
                        <input type="radio" name="rbtnCriminalConvictions" value="Yes" />
                        <input type="radio" name="rbtnCriminalConvictions" value="No" />        
                </div> 
                <div class="itemField">
                    <div class="listDiv2">If Yes, please list each offenceor prosecution, and each sentence your business has received. </div>
                    <div class="listDiv">
                         <textarea name="txbCriminalConvictions" cols="65" rows="5"></textarea>
                    </div>
                </div>
                <div class="itemField">
                    <div class="listDiv2">
                        If you have answered Yes to any of the above questions, please write full detailsbelow. ls below. </div>
                    <div class="listDiv">
                        <textarea name="txbAnswer" cols="65" rows="5"></textarea></div>
                </div>
            </fieldset>
            <fieldset>
                <legend>BussinessDetails dset&gt; </legend><legend>BussinessDetails </legend>
                <div class="itemField">
                    <div class="listDiv2">
                        What is the estimated business turnover? </div>
                    <div class="listDiv">
                        <input type="text" name="txbEstimatedBussiness" /></div>
                </div>
                <div class="itemField">
                    <div class="listDiv2">
                        Number of years since business established? </div>
                    <div class="listDiv">
                        <input type="text" name="txbNumberOfYears" /></div>
                </div>
                <div class="itemField">
                    <div class="listDiv2">
                        Estimated annual wages of business?</div>
                    <div class="listDiv">
                        <input type="text" name="txbAnnualWages" /></div>
                </div>
                <div class="itemField">
                    <div class="listDiv2">
                        Number of employees?</div>
                    <div class="listDiv">
                        <input type="text" name="txbEmployeesNumber" /></div>
                </div>
            </fieldset>
            <fieldset>
                <legend>Sums Insured</legend>
                <div class="itemField">
                    <div class="listDiv2">
                        Legal Liability: $</div>
                    <div class="listDiv">
                        <input type="text" name="txbLiability" runat="server" tabindex="172" id="Text1" /></div>
                </div>
            </fieldset>
            <fieldset>
                <legend>Your Declaration </legend>I declare that I:
                <ul>
                    <ol>
                        1 Have answered all questions truthfully.
                    </ol>
                    <ol>
                        2 Have, in addition, disclosed all material facts to New India (please see Your
                        Duty of Disclosure above)
                    </ol>
                    <ol>
                        3 Agree to the policy terms and conditions.
                    </ol>
                    <ol>
                        4 Authorize:
                    </ol>
                    <ul>
                    <ol>
                        4.1 New India to advise me of its other services from time to time
                    </ol>
                    <ol>
                        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.
                    </ol>
                    <ol>
                        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.
                    </ol>
                    </ul>
                    <ol>
                        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.
                    </ol>
                </ul>
            </fieldset>
        </div>
    </div>