CGU Padlock
insurance application
Please read the following information before you complete the application.
Keep this information for your records.
Please read and keep the policy booklet for this insurance.
When complete, please forward this application to:
• CGU Insurance, GPO Box 9902 in the capital city of your state or • your insurance adviser or
• your local CGU Insurance office.
important that You advise Us immediately of any changes to Your Business, that may result in an increased chance of destruction, loss or damage to property insured or liability to third parties. Some examples of changes about which You should notify Us are:
(a) changes in Your name or directors or partners;
(b) changes to the address or location of your Business;
(c) changes in the nature of your Business or trade or occupation:
(d) alterations in construction of the premises;
When We receive notification of a change We may decide to either:
1. adjust the premium or terms of the Policy, or 2. cancel the Policy in accordance with the
provisions of the Insurance Contracts Act 1984.
4. Workers’ Compensation
The insurances provided by this Policy do not include Workers’ Compensation. It is compulsory for all employees to be insured for Workers’ Compensation and separate cover should be arranged.
5. Underinsurance/Average
If you choose a sum insured that is lower than it would actually cost to replace an item this is called Underinsurance. If this happens you may be required to bear a portion of the loss yourself.
6. Date Recognition Special Exclusion (Year 2000)
This policy is subject to a Date Recognition Special Exclusion, refer to policy wording.
7. The way we handle your Personal Information
We collect personal information from you for the purpose of providing you with insurance products, services, processing and assessing claims. You can choose not to provide this information, however, we may not be able to process your requests. We may disclose information we hold about you to other insurers, an insurance reference service or as required by law. In the event of a claim, we may disclose information to and/or collect additional information about you from investigators or legal advisors. If you wish to update or access the information we hold about you, contact us.
8. Excess
Excess or deductible is the sum of money we will not pay in respect of a claim. The Policy and the Schedule detail the deductibles which may be applicable.
CGU Insurance Limited ABN 27 004 478 371
Extract from the Insurance Contracts Act 1984
Under the terms of the Act We must advise You about the following:
Your duty of disclosure
Before you enter into a contract of general insurance with an insurer, you have a duty, under the Insurance Contracts Act 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer’s decision to accept the insurance risk and, if so, on what terms.
You have the same duty to disclose those matters to the insurer before you renew, extend, vary or reinstate a contract of general insurance. Your duty however does not require disclosure of a matter
◆ that diminishes the risk to be undertaken by the insurer;
◆ that is of common knowledge;
◆ that your insurer knows or, in the ordinary course of its business, ought to already know;
◆ as to which compliance with your duty is waived by the insurer.
Non-Disclosure
If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract.
If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning.
Important Information
1. Delay of Cover
We will not provide any cover, for a period of 48 hours from the time of the commencement of your insurance, for Damage or loss caused by:
(a) bushfire or grassfire; or (b) a named cyclone.
This Exclusion does not apply, however, if this insurance commences directly after another insurance policy covering the same property expired, without a break in cover,
2. Acceptance of the Application
This insurance will not be in force until the completed Application has been received by Us and the risk accepted by Us. We reserve the right to decline any Application.
3. Alterations to Your Business
To ensure continued cover under this Policy it is
CGU Padlock Insurance Application
Please answer all questions. This will help us to process your application quickly.
If you need more space to answer any of the questions, please use a separate sheet of paper.
Any attachments will form part of this application and the declaration will include them.
1. Has any insurer declined an application from You, or cancelled or refused to renew a policy of Yours, required special terms to insure You, or declined or refused a claim?
2. Have you sustained any loss or damage to property, whether or not you made an insurance claim, or had any claims made against You in the last 5 years?
3. Have You, or any person who will receive insurance protection under the proposed policy, been charged with, or convicted of, any criminal offences in the past 10 years?
4. During the last 2 years have You or any other person to whom cover extends under this policy received any threats to life or property (private or business)?
5. Are there any other relevant facts relating to the risk to be insured which You should disclose to Us, to enable a true assessment of Your insurance application?
6. Is any portion of the property to be insured in a state of disrepair or poor condition?
If You have answered Yes to any of questions 1 - 6 above please give full details.
(If insufficient space, please use separate paper).
CGU Insurance Limited ABN 27 004 478 371
General Questionnaire Note: If more than one person is applying for insurance, these questions must be answered in respect of each individual person.
Please tick (✓) Yes or No and give details as requested. Yes No
Question no. Reasons
Insured Details Insured Name
ABN/ACN Telephone Facsimile
Policy start date (dd/mm/yy) Policy End Date (dd/mm/yy)
Interested Parties:
Name of interested party
Address of interested party Postcode
Type of interest (e.g. Mortgagee) Name of interested party
Address of interested party Postcode
Type of interest (e.g. Mortgagee)
Occupation – Please list all tenants business occupation. If insufficient space use notes page.
Intermediary Name Account no.
CGU Insurance use only Policy no. 0 : 1 : R : : : : : : : : LOB ISR
This Application replaces cover note number UW Code: NN992
Claims History/Current Underwriter – List details of all claims in the last 3 years.
Situation of Risk
Sit. Address Post Code Occupied as Construction
1.
2.
3.
4.
5.
Details of Property to be Insured (complete for each situation in order as above) Construction: C = Concrete B = Brick F = Fibro I = Iron O = Other
Sit. Walls Frame Roof Floors Age Stories Floor Area
1.
2.
3.
4.
5.
Security & Risk Management (complete for each situation in order as above)
Sit. Smoke Detectors Hose Reels Sprinklers Extinguishers Fire alarms
1.
2.
3.
4.
5.
Declared Values – Section 1 Property (complete for each situation in order as above)
Sit. Buildings Contents Specified Items Total
1. $ $ $ $
2. $ $ $ $
3. $ $ $ $
4. $ $ $ $
5. $ $ $ $
Declared Values – Section 2 Loss of Income (complete for each situation in order as above)
Sit. Annual Rent Other Income Indemnity Period Total
1. $ $ $ $
2. $ $ $ $
3. $ $ $ $
4. $ $ $ $
5. $ $ $ $
Has any property to be insured previously been flooded? Yes No
Is the property serviced by a town water supply? Yes No
Is the property professionally managed? Yes No
Is the situation serviced by an operational fire brigade? Yes No
Is the property under a heritage or national trust or other protection order? Yes No Section 1 – Property
Building and Contents Total Sum Insured $ (the total of all buildings and contents listed on page 4)
Specified Items Total Sum Insured $
(the total of all specified items listed on page 4)
Total Sum Insured $
Specified Items (list all items and sum insured separately)
Section 2 – Loss of Income
1. Annual Rent $
2. Other Income $
3. Total Annual Income $
4. Indemnity Period Months
5. Total of Annual Income (X) Indemnity Period 12 months X (1)
18 months X (1.5) 24 months X (2) 36 months X (3)
$
6. Additional Increased Cost of Working $ 7. Accountants Fees
(if more than $5,000 cover required) $
Total Sum Insured
(the sum of 5, 6 and 7) $
Section 3A – Theft
Building and Contents Total Sum Insured $ (the total of all buildings and contents listed above)
Specified Items Total Sum Insured $
Total Theft Sum Insured $
Specified Items (list all items and sum insured separately)
Section 3A – Money In Transit/Bank/NightSafe/
ATM $ 50,000 On Premises
(Business Hours) $ 50,000
In Locked Safe/Strongroom $ 50,000 In Private Residence $ 5,000
On Premises
(Outside Bus. Hours
not in Locked safe) $ 5,000
Section 3C – Rent Default
Rent Default (maximum 26 weeks cover)
Annual Rent $ Excess 1st 4 weeks rent
Section 4 – Glass
Internal and External Glass Sum Insured $ Replacement Value
Are you (the Property Owner) responsible for insuring the building glass? Yes No Section 5 – Taxation Audit
Total Sum Insured $ 5,000 Excess nil
Do you require a higher sum insured ?
If yes, insert sum insured required $
Has the Australian Taxation office served a general notification to your industry that it will
be carrying out audits of your industry? Yes No
Section 6 – Legal Costs OH&S Breach
Total Sum Insured $100,000 Excess nil
Section 7 – Liability
Limit of Indemnity $ Excess $500 Property Damage claims only
Annual Turnover $
Section 8 – Machinery
Is Blanket Machinery cover required? Yes No
If No, specify sum insured required here and detail items of machinery together with new replacement value per item below
Is Air Conditioning plant utilizing centrifugal compressors or other air conditioning plant
which has a rated cooling capacity greater than 20 kw? Yes No
If yes, please specify items below and advise new replacement value of
air conditioning plant $
Specified Machinery
(a) Is machinery and plant regularly serviced?
(b) Is any machinery or plant item more than 20 years old, or not in current production?
(c) Has any machinery or plan item been modified to perform other than originally intended by the manufacturer?
If yes, Please provide details of the modifications
Standard Excess - Sections 1, 2, 3A, 3B and 4
A Standard Excess will be applied for each and every claim for Section 1 - Property, 2 - Loss of Income, 3A - Theft, 3B - Money and 4 - Glass cover. Unless otherwise agreed, the following Standard Excess will apply for these Sections.
Total Sum Insured Sections 1 & 2 Combined Up to $2,500,000
From $2,500,000 to $5,000,000 From $5,000,000 and above
Excess
$250
$500
$1,00 or 0.01% of total sum insured
Do you wish to vary the Standard Excess Yes No
If yes, please specify the excess required
For all other Sections the excess will be specified within the particular section.
$
Duty of Disclosure
In answering our questions, you must be honest, and tell us anything that you or a reasonable person in the circumstances would include in your answers. It is important that you understand you are answering the questions for yourself and anyone else to whom the questions apply.
We may be entitled to reduce our liability under the contract, or cancel the policy, or refuse to pay a claim by anyone insured, if you have not answered our questions in this way.
Do you understand and accept your duty of disclosure? Yes No
Has any insurer declined an application for You, or cancelled or refused to renew a policy
of Yours, required special terms to insure You, or declined or refused a claim? Yes No
Declaration – To be completed by each person applying for insurance I/We declare that:
a) the particulars and statements in this Application are true, correct and complete, and contain all information known to me/us.
b) I/we agree to accept the insurance subject to the terms, conditions, exclusions and limitations of the Policy.
c) I/we have received the Important Notices under the Insurance Contracts Act 1984.
I/We authorise CGU Insurance Limited to obtain or supply details of insurance claims and other relevant information.
Signature of Applicant Date Signature of Applicant Date
/ / / /
Please indicate the number of additional pages attached to this application
Premium Calculations
Premium FSL GST Stamp Duty Total
$ $ $ $ $
Application Guidelines General
Underinsurance/Average - When Your Sum Insured is less than 80% of the full amount You should insure for, You may not receive full compensation in the event of a loss. Average puts You in a position where You proportionately share the loss.
Underinsurance/Average applies to Property, Loss of Income and Rent Default.
Section 1: Property
Under this Section You have a Sum Insured for Buildings and Contents and Specified Items (if Specified Items are insured).
When establishing your Sums Insured they should represent the amount it would cost to replace the property insured in its entirety. So that you are not disadvantaged by the Underinsurance/Average clause, you should specifically indicate any property that you do not wish to insure.
Accidental Damage – The amount payable for any loss for which a claim would be payable under the Property Section for Accidental Damage is limited to the Sum Insured you have taken for Section 1 - Property.
Section 2: Business Interruption
Under this Section You can insure Gross Rent and other Income incidental to Your Business.
Uninsured working expenses should be those expenses that will reduce in direct proportion to a reduction in income.
The indemnity period should be the period You consider it would take to restore the income of Your business to the same position it was on the day the loss occurred. This should be calculated as the amount of time it would take to rebuild your property. If Your indemnity period exceeds 12 months Your Sum Insured should be increased proportionately.
Section 3A: Theft of Property
Your Sum Insured is set at 100% of the cover you select for Section 1 Property. If you have artworks or curios in excess of
$50,000, these should be specified in your application.
Section 3B: Money
Your cover includes the following cover types: Money in Transit, Money on Premises during Business Hours, Money in Securely Locked Safe or Strongroom, Money on Premises outside Business Hours and Money in Private Residence. Separate limits apply to each of these cover types and you should ensure that these meet your requirements.
Section 4: Glass
Specified Glass - is for insuring glass other than internal or external glass such as signs and a Sum Insured is required for these items.
Section 5: Taxation Investigation
Covers the costs incurred by Your Accountant or Registered Tax Agent (after receiving notification from the Australian Taxation Office) in conducting taxation audits or detailed investigations in relation to Your liability to pay income tax, fringe benefits tax, capital gains tax or sales tax, A New Tax System (Goods and Services Tax), superannuation payments tax, termination payments tax, but does not include the amount of such tax and fines or penalties.
Section 6: Costs for Occupational Health & Safety breaches
This section covers any reasonable legal costs and expenses incurred in appealing against the imposition of a fine; a prohibition notice; or a determination by any court or tribunal under any workplace, occupational heath and safety, or similar legislation.
Section 7: Liability
You should ensure that the Limit of Indemnity You select is adequate. Your Limit of Indemnity should be sufficient to cover court awards made against You some years after the Personal Injury or Damage to Property happens. For Products Liability the Limit of Indemnity must be sufficient to cover all claims happening during any one Period of Insurance.
Section 8: Machinery
You can insure for Blanket Cover or Specified items. Blanket Cover will insure all your Machinery, Electronic Equipment and Pressure Equipment.
Certain items of Air conditioning plant are excluded. These are known as air conditioning plant utilizing centrifugal compressors or any other air conditioning plant which has a rated cooling capacity greater than 20 kw and you must specify these items if you want cover.
The Sum Insured should be sufficient to include removal, transport, repair and replacement of the machine and the cost of delivery to the site of any parts required. The amount payable in respect of a breakdown will not exceed the market value of the machine at the time of loss.
CID0193 REV0 11/08
