Client Code:*Name of person completing questionnaire:*Insured Name:*1) Are there any changes in your business activities / operations?* Yes No If YES, please advise details2) Have there been any material changes to fire and theft protection alarms, devices and the like during the past 12 months? (e.g. disconnection or dismantling or installation of any services)* Yes No If YES, please advise details3) Is there any history of flood damage at the insured location(s)?* Yes No If YES, please advise detailsMachinery Breakdown4) The level of cover and sums insured must be reviewed to ensure they are adequate and continue to meet your requirements. So that we can market your renewal please provide a list of all machinery (e.g. 2001 40hp submersible pump, 1997 50hp centrifugal pump, cool room motor).*5) Have you purchased any machinery / equipment in the last policy period?* Yes No If YES, please advise details6) Do you have any centrifugal or submersible pumps?* Yes No If YES, please advise detailsLiability7) Estimated Turnover for the forthcoming year ($)*8) Number of principals*9) Number of Staff*10) Estimated Payroll*11) Are Contractors/Sub-contractors used?* Yes No Activities performed*Estimated Annual Payments made: $*Do you sight current Public Liability insurance prior to work commencing?* Yes No 12) Are Labour Hire personnel used?* Yes No Activities performed*Estimated Annual Payments made: $*Do you sight current Public Liability insurance prior to work commencing?* Yes No 13) Any demolition activities* Yes No Does demolition exceed 3.5 metres in height? Yes No If yes, state maximum heightIf yes, percentage of turnover14) Do you Dry Hire? (Hire out plant without an operator)* Yes No 15) Please provide a description of your business activities to ensure your Public Liability cover is sufficient.*Farm and Private Motor16) If you Hire-In Plant or Vehicles (including trailers), please advise the estimated maximum duration of each hire and also the highest valued item.*17) If not already provided in your Policy are you interested in an excess free windscreen cover for an additional premium?* Yes No 18) If available, are you interested in covering the hire costs for a similar vehicle following an accident?* Yes No 19) Are there any changes in your business activities/operations?* Yes No If YES, please advise detailsDriver Disclosures:20) Please provide details of any person under 25years of age or with less than two (2) years driving experience, that may drive or operate any of the insured units:*21) Details of any Motor Insurance and/or claims refused and/or cancelled and/or imposed special terms in the last five (5) years:*22) To the best of your knowledge, details of any convictions for driving under the influence of alcohol or drugs (DUI) and/or exceeding the prescribed content of alcohol (PCA) in the last three (3) years:*23) To the best of your knowledge, have any employed drivers had a licence suspended or cancelled in the last five (5) years?* Yes No If YES, please provide details24) To the best of your knowledge, have any employed drivers been convicted of a total of more than two (2) traffic offences (excluding parking) in the last three (3) years?* Yes No If YES, please provide detailsClaims25) Details of any claims that have occurred, but have not yet been reported.*26) After specific inquiry, details of any facts, circumstances or incidents (other than those already disclosed, notified to your insurer) which could give rise to claims in the future.*Information we have provided to City Rural Insurance, is to the best of our knowledge correct. Please type your name below:*CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
