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Public Liability Quote Request
Public Liability Quote Request
Please complete this form to arrange your insurance quote with Webber Insurance. We use this form in place of a paper form to submit to the insurers to arrange a quote. Please note that your information is saved on our server as you enter it, which will allow you to save and continue your form later on. To save the form, please click the link at the bottom of this page.
Name
*
First
Last
Business Name
ABN
Email
*
Phone
*
Address
*
Street Address
Address Line 2
City
State
Postcode
Country
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo, Democratic Republic of the
Congo, Republic of the
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Greenland
Grenada
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Saint Martin
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Sint Maarten
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Sudan, South
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Virgin Islands, British
Virgin Islands, U.S.
Yemen
Zambia
Zimbabwe
Current Insurance
Do you currently have Public Liability insurance?
Yes
No
Who is your current insurer
*
When is your renewal date
*
Business Details
How many years has this business been in operation?
*
Less than 1 year
1 - 3 years
3- 5 years
5 - 10 years
10 years +
Total Business Turnover
*
What states does your business operate in?
NSW
VIC
QLD
SA
WA
TAS
NT
ACT
Overseas
Percentage of turnover from NSW
*
Percentage of turnover from VIC
*
Percentage of turnover from QLD
*
Percentage of turnover from SA
*
Percentage of turnover from WA
*
Percentage of turnover from TAS
*
Percentage of turnover from NT
*
Percentage of turnover from ACT
*
Percentage of turnover from Overseas
*
Business Activities
Please describe your business activities and/or occupation
*
Do you regularly work away from your usual business location?
*
Yes we do
Not at this stage, but maybe in the future
No we dont
Percentage of your turnover received from this work
*
Is your business involved with any of the following?
*
Welding
UndergroundWork
Off-shore latform Work
Aircraft, Watercraft or Hovercraft
Rail Equipment or in the Rail Corridor
Blasting
NONE OF THE ABOVE
Please provide further details of this work
*
Contractors & Labour Hire
Do you engage contractors for any of your work?
*
Yes
No
Type of work Contractors undertake on your behalf?
*
Estimated fees paid to contractors for LAST 12 months
*
Estimated fees paid to contractors for NEXT 12 months
*
Do you enter into contracts with each and every contractor?
*
Yes I do
No I dont
Do all contracts have an indemnity or waiver of subrogation in your favour?
*
Yes they do
No they dont
I am unsure
If NO, please explain the steps you take to minimise injuries to your contractors?
*
If NO, please explain the steps you take to minimise injuries to your contractors?
*
Do you hire out any employees to third parties on a Labour-Hire basis?
*
Yes I do
No I dont
Not at this stage but maybe in the future
Estimated Turnover / Income received from Labour-Hire?
*
What activities will they undertake?
*
Products Insurance
With regards to Products, do you
*
Manufacture
Import
Export
Re-Package
Distribute
WE DO NOT HAVE ANY PRODUCTS
Are any of your products used in or at
*
Aircraft
Vehicles
Watercraft
Hovercraft
Rail Equipment
Power Stations
Chemical / Petrochemical Plants
Mining / Drilling Sites
NONE OF THE ABOVE
Do you have quality control procedures in place for all of your products?
*
Yes
No
Have you ever recalled a product because of a potential safety hazard?
*
Yes
No
Manufactured Products
Products Manufactured
*
Turnover from Manufactured Products
*
Can you identify the source of every item used in their Manufacture?
*
Yes
No
Imported Products
Products Imported
*
Turnover from Imported Products
*
Countries of Origin for Imported Products
*
Do you modify Products that you Import?
*
Yes
No
Exported Products
Products Exported
*
Turnover from Exported Products
*
Countries of Origin for Exported Products
*
Do you modify Products that you Export?
*
Yes
No
Repackaged Products
Products Re-Packaged
*
Turnover from Re-Packaged Products
*
Other than Re-Packaging, do you modify these Products in any way?
*
Yes
No
Distributed Products
Level of Coverage Required
Level of Cover Required
*
$5,000,000
$10,000,000
$20,000,000
Other
Please advise limit of cover required
*
Contract Liability
Have you or will you sign any contracts (Other than for a property lease)
*
Yes, I have signed a contract
Yes, I will be signing a contract
No, I haven't signed a contract
I am unsure for now
If you have or will be signing a contract, will you assume liability or hold any party harmless
*
Yes, I will
No, I wont
I am unsure
If yes, please upload a copy of the relevant contracts
Claims Experience
After investigation, are there any circumstances for which YOU in the past 7 years were or could be fined or required to pay a penalty?
*
Yes
No
After investigation, have any Principals or staff members ever been subject to disciplinary proceedings for professional misconduct?
*
Yes
No
If yes, please provide further details
*
If yes, please provide further details
*
After investigation, have there been any claims &/or uninsured losses, &/or circumstances of which could give rise to a claim?
*
Yes
No
If yes, please provide further details
*
Previous Insurance & Other History
Have you ever had any
*
Insurance declined or cancelled
Insurance renewal refused
Special conditions imposed on your insurance
Increased excess imposed on your insurance
Claims denied for this class of insurance
Criminal charges &/or convictions
Financial trouble resulting in an administrator being appointed &/or being declared bankrupt
NONE OF THE ABOVE
Please tick all that apply
If yes, please provide further details
*
Other Insurances
Do you require a quote on insurance other than Public Liability?
*
Professional Indemnity
Contract Works
Business Insurance
Commercial Motor Insurance
Workers Compensation
Personal Accident (Income Protection)
Other
NO THANKS
If other, please advise details
*
Confirmation of Details
Click to view our Financial Services Guide
Click to view our Privacy Policy
Click to view Important Information
Please tick all to confirm that you have read the following documents:
*
Financial Services Guide
Privacy Policy
Duty of Disclosure
Anything else you wish to request or tell us?
Signature
This electronic signature will be treated the same as if signed personally.
This is signature..
Name
Insurance Quote
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