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Workers Compensation Questionnaire

Workers Compensation Questionnaire 2023

YOUR INSURANCE DETAILS

Are you currently insured
Do you want to upload your current policy or renewal notice
Maximum upload size: 5MB

YOUR DETAILS

Full Name
Full Name
First
Last

Physical Address

Address
Address
City
State/Province
Zip/Postal
Any Claims
Any Convictions
Ever Been Declared Bankrupt
Structure
11 Digits
GST Registered

Number of Employees Per State

Sub-contractors
Want to Insure Them

Please Provide a Break-up of the Estimated Wages

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 expect to know, is relevant to the Insurer's decision whether to accept the risk of Insurance 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 matter.

  • that diminishes the risk to be undertaken by the Insurer
  • that is common knowledge
  • that your Insurer knows or, in the ordinary course of business, ought to know
  • as to which the 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 the 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.

Answer all questions correctly to comply with your duty of disclosure

Do you understand your Duty of Disclosure

DECLARATION

I/We hereby declare that:

My/Our attention has been drawn to the Important Notice of this Proposal form and further I/We have read these notices carefully and acknowledge my/our understanding of their content by my/our signature/s below.

The above statements are true, and I/we have not suppressed or misstated any facts and should any information given by me/us alter between the date of this Proposal form and the inception date of the insurance to which this Proposal relates I/we shall give immediately notice thereof.

I/We authorise you, to collect or disclose any personal information relating to this insurance to/from any insurers or insurance reference service. Where I/we have provided information about another individual I/we declare that the individual has been or will be made aware of that fact.

I/we also confirm that the undersigned is/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this Proposal form, and I/we complete this Proposal form on their behalf.

Where a Policy is issued on a “minimum and deposit” premium basis, the annual premium is a minimum and deposit premium, which means that there is no refund of any premium or fees and charges in the event you cancel the policy before the normal expiry date or the policy is cancelled by the insurer prior to the normal expiry date. By signing this proposal form you acknowledge your understanding and acceptance of this condition.

Your Name
Your Name
First
Last

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