General Information
Insured Name
Postal Address
Business Description
Years in Operation
Work Phone No.	Mobile No.
Email
Business Information
Estimated Annual Turnover	$
Number of Employees (Including partners and directors performing employee duties)
Do you engage subcontractor’s or Labour Hire Staff	Yes/No
If so, what amount is paid to Subcontractor’s Annually?	$
Business Activities (Must add up to 100% of Turnover)
Total	100%
Claims Information
No. of claims in the last 5 Years
Details: (Dates, Amounts Paid, Insurer Information)
Machinery Information
Are Any of your Machines Used or Expected to be used…
On, in or under water or in tidal areas	Yes/No
Underground	Yes/No
In demolition	Yes/No
In Connection with Oil and/or gas exploration	Yes/No
In Connection with any other hazardous activity	Yes/No
If “Yes” to any of the above, please provide details:

Machinery Information (Continued)
Item No	Type	Year	Make/Model	Serial No	Sum Insured	Interested Parties	Attachments
1	$
2	$
3	$
4	$
5	$
6	$
7	$
8	$
9	$
10	$
11	$
12	$
13	$
14	$
15	$
Road Registered Items
Item No	Type	Year	Make/Model	Rego	Sum Insured	Interested Parties	Accessories/ Modifications
1	$
2	$
3	$
4	$
5	$
Security/Risk Management
What is the address of your Depot?
What security is in place for your plant/machinery at the depot?
Do you keep plant on site overnight?	Yes/No
What Security is in place for your plant/machinery on site?
Hired-In Plant
Does your Business Require Hired-In Plant Cover	Yes/No
Estimated Annual Hiring Fees incurred for hiring Machines	$
Estimated Market Value of the most valuable individual item of plant	$
Estimated Market Value of all hired in plant at any one time (maximum)	$
Types of Machines to be hired in (Excavators, Skid Steers, Backhoes, Graders, Dozers etc.):

Policy Information
Current Policy Expiry
Inception Date Required
Additional Coverages – If Required
Public/Products Liability	$10,000,000 / $20,000,000 / Please Specify:
Machinery Breakdown	Yes/No
Financial Protections:	Loss of Revenue	Yes/No
Increased Additional Cost of Working	Yes/No
Lease Payments Protection	Yes/No
Lease Value Protection	Yes/No
Any Additional Information or facts you want us to be aware of

I hereby declare that the above statements and particulars, whether in my own hand or not, are true, and that no facts have been suppressed or mis-stated.

I understand that non-disclosure or misrepresentation of a material fact may enable underwriters to reduce or decline to pay a claim.

I understand that the signing of this proposal does not bind me (or underwriters) to complete the insurance but agree that should a contract of insurance be concluded, this proposal and the statements made herein shall form the basis of the contract.

Your Rights and Obligations

The Duty of Utmost Good Faith: The Insurance Contracts Act 1984 states the following: “A contract of insurance is a contract based on utmost good faith and there is implied in such a contract a provision requiring each party to it to act towards the other party, in respect of any matter arising under or in relation to it, with the utmost good faith.

Your Duty of Disclosure

Before you enter in to a contract of general insurance with an insurer, you have a duty under the Insurance Contracts Act 1984 to disclose every matter which you know, or could reasonably be expected to know, is relevant to the insurer’s decision whether to accept the risk, and if so, on what terms. You have the same duty to disclose such matters before you renew, extend, vary or reinstate a contract of insurance.

Your duty, however, does not require you to disclose a matter:

That diminishes the risk to be undertaken by the insurer;

That is common knowledge;

That the insurer knows, or in the ordinary course of business as an insurer, ought to 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 insurers may be entitled to reduce their liability under the contract in respect of any claim, or may cancel the contract. If your non-disclosure is fraudulent, the insurers may also have the option of avoiding the contract from its beginning.

Cancellation

You may cancel the policy at any time by notifying us in writing

Subject to the provisions of the Insurance Contracts Act 1984, the underwriters may cancel the policy by giving you notice in writing of the date on which cancellation is to take effect. Such notice is to be delivered personally, emailed or posted by certified mail or to your address last notified to us. Proof of mailing is sufficient proof of notice.

Privacy

R&M Insurance Brokers respects your privacy and complies with the Privacy Act and the National

Privacy Principles.

Any personal information you provide may be held by us, our representatives or your insurer(s). It may be used by relevant staff in making a decision concerning your insurance application. It may also be used for the purposes of arranging and servicing any cover that may be issued and administering any claims. Information may be passed to overseas insurers, loss adjusters and surveyors for these purposes. In signing this proposal form or otherwise seeking insurance through us, you are agreeing to these terms. Under privacy legislation, you can request access to your personal information by contacting us at any of our offices during normal business hours.