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Form name:

<div class="rounderCornerMiddle">
    <div id="wrapper">
        <div class="headerText">
            PROPOSAL FOR 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>
        </div>
        <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 rows="5" cols="22" name="txbBussinessPhysicalAddress"></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 rows="5" cols="22" name="txbPostalAddress"></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">
                    E mail:
                </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" value="Yes" name="rbtnInsurer" />
                <input type="radio" value="No" name="rbtnInsurer" />
            </div>
            <div class="checkboxItemField">
                <label>
                    Has any insurer ever refused to pay your insurance claim?</label>
                <input type="radio" value="Yes" name="rbtnInsurenceClaim" />
                <input type="radio" value="No" name="rbtnInsurenceClaim" />
            </div>
            <div class="checkboxItemField">
                <label>
                    Have you made any insurance claim in the last five years?</label>
                <input type="radio" value="Yes" name="rbtnInsurenceinFiveYears" />
                <input type="radio" value="No" name="rbtnInsurenceinFiveYears" />
            </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" value="Yes" name="rbtnCircumstances" />
                <input type="radio" value="No" name="rbtnCircumstances" />
            </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? If yes, please list each offence
                    or prosecution, and each sentence your business has received.</label>
                <input type="radio" value="Yes" name="rbtnCriminalConvictions" />
                <input type="radio" value="No" name="rbtnCriminalConvictions" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If you have answered yes to any of the above questions, please write full details
                    below.
                </div>
                <div class="listDiv">
                    <textarea rows="5" cols="65" name="txbAnswer"></textarea></div>
            </div>
        </fieldset>
        <fieldset>
            <legend>Business Details </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>
            <div class="checkboxItemField">
                <label>
                    Is any work done away from your business?</label>
                <input type="radio" value="Yes" name="rbtnWorkDone" />
                <input type="radio" value="No" name="rbtnWorkDone" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If Yes, please describe.</div>
                <div class="listDiv">
                    <textarea cols="35" rows="4" name="txbWorkDone"></textarea></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Does your business involve dangerous operations (e.g. hazardous substances, use
                    of naked or open heat sources, excavation of land)?</label>
                <input type="radio" value="Yes" name="rbtnWorkInvolve" />
                <input type="radio" value="No" name="rbtnWorkInvolve" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If Yes, please describe.</div>
                <div class="listDiv">
                    <textarea cols="35" rows="4" name="txbWorkInvolve"></textarea></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Does your business operate outside New Zealand in any way</label>
                <input type="radio" value="Yes" name="rbtnBussinessOperate" />
                <input type="radio" value="No" name="rbtnBussinessOperate" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Please describe land on which your business is situated:</div>
                <div class="listDiv">
                    <textarea cols="35" rows="4" name="txbDescribeLand"></textarea></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Does your business discharge dangerous or toxic substances?</label>
                <input type="radio" value="Yes" name="rbtnBussinessDischarge" />
                <input type="radio" value="No" name="rbtnBussinessDischarge" />
            </div>
            <div class="checkboxItemField">
                <label>
                    Do you store other people's property at your business?</label>
                <input type="radio" value="Yes" name="rbtnPeoplesProperty" />
                <input type="radio" value="No" name="rbtnPeoplesProperty" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If Yes, please state type, value and location of those items.</div>
                <div class="listDiv">
                    <textarea cols="35" rows="4" name="txbPeoplesProperty"></textarea>
                </div>
            </div>
            <div class="itemField">
                <strong>Has your business ever been investigated, issued with an official notice, prosecuted
                    or sued under the: </strong>
            </div>
            <div class="checkboxItemField">
                <label>
                    &bull; Building Act?</label>
                <input type="radio" value="Yes" name="rbtnBussinessAct" />
                <input type="radio" value="No" name="rbtnBussinessAct" />
            </div>
            <div class="checkboxItemField">
                <label>
                    &bull; Health and Safety in Employment Act?</label>
                <input type="radio" value="Yes" name="rbtnHealthAndSafty" />
                <input type="radio" value="No" name="rbtnHealthAndSafty" />
            </div>
            <div class="checkboxItemField">
                <label>
                    &bull; Fair Trading Act?</label>
                <input type="radio" value="Yes" name="rbtnFairTrading" />
                <input type="radio" value="No" name="rbtnFairTrading" />
            </div>
            <div class="checkboxItemField">
                <label>
                    &bull; Consumer Guarantees Act?</label>
                <input type="radio" value="Yes" name="rbtnConsumer" />
                <input type="radio" value="No" name="rbtnConsumer" />
            </div>
            <div class="checkboxItemField">
                <label>
                    &bull; Resource Management Act?</label>
                <input type="radio" value="Yes" name="rbtnResourceManagement" />
                <input type="radio" value="No" name="rbtnResourceManagement" />
            </div>
            <div class="checkboxItemField">
                <label>
                    &bull; Any other statute, which affects your business?</label>
                <input type="radio" value="Yes" name="rbtnStatute" />
                <input type="radio" value="No" name="rbtnStatute" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If you answered <strong>yes</strong>to any of above these questions, please write
                    full details</div>
                <div class="listDiv">
                    <textarea cols="55" rows="5" name="txbDetails"></textarea></div>
            </div>
        </fieldset>
        <div class="itemField">
            <div class="listDiv">
                <strong>OPTIONAL LIABILITY COVER</strong></div>
        </div>
        <fieldset>
            <div class="checkboxItemField">
                <label>
                    Do you require the Exemplary Damages in NZ extension?</label>
                <input type="radio" value="Yes" name="rbtnExemplary" />
                <input type="radio" value="No" name="rbtnExemplary" />
            </div>
        </fieldset>
        <fieldset>
            <legend>PRODUCT LIABILITY COVER REQUIREMENTS </legend>
            <div class="itemField">
                <div class="listDiv2">
                    What goods or services do you provide?</div>
                <div class="listDiv">
                    <textarea rows="4" cols="45" name="txbServices"></textarea></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Are the goods manufactured by you?</label>
                <input type="radio" value="Yes" name="rbtnManufactured" />
                <input type="radio" value="No" name="rbtnManufactured" />
            </div>
            <div class="checkboxItemField">
                <label>
                    Are the goods dangerous?</label>
                <input type="radio" value="Yes" name="rbtnGoodsDangarous" />
                <input type="radio" value="No" name="rbtnGoodsDangarous" />
            </div>
            <div class="checkboxItemField">
                <label>
                    Are the goods guaranteed by you?</label>
                <input type="radio" value="Yes" name="rbtnGuaranted" />
                <input type="radio" value="No" name="rbtnGuaranted" />
            </div>
            <div class="checkboxItemField">
                <label>
                    Do you have quality control systems for the goods?</label>
                <input type="radio" value="Yes" name="rbtnQualityControl" />
                <input type="radio" value="No" name="rbtnQualityControl" />
            </div>
        </fieldset>
        <fieldset>
            <legend>MOTOR SERVICE AND WATERCRAFT REPAIR LIABILITY COVER REQUIREMENTS </legend>
            <div class="checkboxItemField">
                <label>
                    Do you service ,supply,and/or repair motor vehicles?</label>
                <input type="radio" value="Yes" name="rbtnServiceSupply" />
                <input type="radio" value="No" name="rbtnServiceSupply" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If yes please describe</div>
                <div class="listDiv">
                    <textarea cols="45" rows="4" name="txbServiceSupply"></textarea></div>
            </div>
            <div class="checkboxItemField">
                <label>
                    Do you service ,supply,and/or watercraft</label>
                <input type="radio" value="Yes" name="rbtnWaterCraft" />
                <input type="radio" value="No" name="rbtnWaterCraft" />
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    If yes please describe</div>
                <div class="listDiv">
                    <textarea cols="45" rows="4" name="txbWatercraft"></textarea></div>
            </div>
        </fieldset>
        <fieldset>
            <legend>SUMS INSURED:</legend>
            <div class="itemField">
                <div class="listDiv2">
                    General Legal Liability ($)</div>
                <div class="listDiv">
                    <input type="text" name="txbLegaLiability" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Bailment ($250,000 standard)</div>
                <div class="listDiv">
                    <input type="text" name="txbBailment" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Defective Design ($250,000 standard)</div>
                <div class="listDiv">
                    <input type="text" name="txbDefective" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Forest &amp; Rural Fires Act ($250,000 standard)</div>
                <div class="listDiv">
                    <input type="text" name="txbForest" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Motor Service &amp; Repair ($250,000 standard)</div>
                <div class="listDiv">
                    <input type="text" name="txbMotorService" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Removal of Support ($250,000 standard)</div>
                <div class="listDiv">
                    <input type="text" name="txbRemoval" /></div>
            </div>
            <div class="itemField">
                <div class="listDiv2">
                    Watercraft Repair ($250,000 standard)</div>
                <div class="listDiv">
                    <input type="text" name="txbWatercraftRepair" /></div>
            </div>
        </fieldset>
        <fieldset>
            <legend>YOUR DECLARATION </legend>
            <div class="itemField">
                I declare that I:
                <br />
                <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>
                    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.
                </ul>
            </div>
        </fieldset>
    </div>
</div>