Atlantic Plumbers Liability Plan - Request Quotation

To receive our proposal for your insurance requirements, please complete and submit this form. One of our consultants will contact you as soon as possible to discuss your request.

This form is also available as a PDF which can be downloaded, completed and returned by post or fax.

Personal Details

Title: First Name: *
    Surname: *

Business Details

Business Name: ABN:
Address: Suburb:
    State:
    Postcode:
       
Phone: * Facsimile:
Email: *

Annual Gross Turnover

State Gross Annual Turnover (labour and materials) LAST 12 mths
  NEXT 12 mths

Is your estimated turnover less than $35,000? If 'yes', provide details of additional sources of income.


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List the activities undertaken and indicate the percentage of your total income each activity represents.
(e.g. Airconditioning / boilermaker / installation / roofing / gasfitting / type B gasfitting).

Activity % Activity %

If specialised type B gasfitting included in above please supply details.


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Do you carry out work on cooling towers?
Indicate the type of premises you will be working on:
Residential Commercial Factory Industrial* Non Plumbing work*

If Industrial work (plants / large scale factories) included in above please supply details.


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If Non Plumbing work included in above please supply details.


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Sub Contractors

Will you use Sub Contractors?
Estimated payment to Sub Contractors? $
Will work performed by Sub Contractors total more than 25% of estimated turnover?
Do you ensure Sub Contractors are correctly insured?

Insurance History

Have you, your business, or any Director, Proprietor or Partner of your business ever had?...

insurances cancelled or had special conditions imposed?
a proposal for insurance declined?
an insurer refuse to renew a policy?
any claims, uninsured losses, damage or liabilities that have involved your business in the last 5 years?

If YES please provide details.


200 characters left.

Certified Plumbers

Names of Certified Plumbers Licence Number Licence Type (eg. A or B)
Number of workers on tools incl. Directors, Partners, Apprentices, Labourers

Commencement Date and Limit of Cover

Date to start insurance from with $ Limit of Cover
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