Hire & Rental Specialty – Application Form
Hire & Rental Specialty –Application Form
Important Notices
Please read these Important Notices before applying for this insurance.
This application must be fully completed and you must report full details of all circumstances which have become known to you or that a claim arising from an event may be made against you. See your Duty of Disclosure below. If there is insufficient space on the application, please use a separate signed and dated headed sheet of paper.
Where available, brochures, standard contract conditions, agreements, letters of appointment should be provided.
Duty of Disclosure
Under the Insurance Contracts act 1984 (the Act), you have a duty of disclosure. You are required before you enter into, renew, vary extend or reinstate your Policy, to tell us everything you know and that a reasonable person in the circumstances could be expected to know, is a matter that is relevant to our decision whether to insure you, and anyone else to be insured under the Policy, and if so, on what terms.
You don’t need to tell us about any matter:
- that reduces the risk,
- is of common knowledge,
- that we already know, or ought to know in the ordinary course of our business as an insurer, or
- we indicate we do not want to know.
If you do not tell us
If you do not comply with your Duty of Disclosure we may:
- reduce or refuse to pay a claim, or
- cancel your Policy.
If your non-disclosure is fraudulent, we may also have the option of avoiding the Policy from its beginning.
Right of Recovery
Where another person or entity would be liable to compensate you for any loss or damage covered by this insurance but you have agreed with that person or entity at any time that you would not seek to recover that loss or damage, this insurance policy will not provide cover for such loss or damage.
Third Party Interests
You must inform Us of the interests of all third parties, for example financial institutions, lessors to be covered by this insurance. We will protect their interests only if you have informed us of them and we have noted them on the Certificate.
Privacy
Privacy legislation regulates the way private sector organisations can collect, use, keep secure and disclose personal information. PSC Underwriting has developed a privacy policy which explains what sort of personal information we hold about you and what we do with it. You can obtain a copy of the PSC Underwriting Privacy information brochure by contacting us at 1300 556 826 or from our website
Brokerage: / Click here to enter text. / Phone: / Click here to enter text.Name: / Click here to enter text. / Email: / Click here to enter text.
Policies Required: / Business Pack ☐ / Liability ☐ / Hire Plant & Equipment ☐
Insured Name: / Click here to enter text.
Trading As: / Click here to enter text.
ABN: / Click here to enter text. / Website: / www.
Period of Insurance: / From. to: To. / Insurer: / Current Insurer.
Main Location: (For more locations please complete business pack proposal form per location)
Street: / Street Address / Suburb: / Suburb / State: / State / PC: / P/C
Please Describe Your Business Activities:
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Please Advise of any proposed changes in your business activities before Your next renewal date:
For Example: new hiring sectors, repair services, online sales
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Unacceptable Activities
Hiring of Jumping Castles / Hiring of Watercraft / Any involvement in mining, power stations, aviation, dams, offshore platforms, Motor Vehicle Hire
Use of Explosives / Demolition Activities
Year Business Established: / Click here. / Are you a member of any industry Associations? / Yes☐No ☐
If yes, please provide details: / Click here to enter text.
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Annual Turnover: / $Click here / Number of Staff / Click here
Please provide the split of turnover from hire of the following items:
Agricultural Equipment / Click here % / Catering Equipment / Click here %
Cleaning Equipment / Click here % / Computer Equipment & Electronics / Click here %
Construction Equipment / Click here % / Earthmoving Equipment / Click here %
Landscaping Equipment / Click here % / Lifting Equipment / Click here %
Marquees/Dance Floors / Click here % / Party Hire Equipment / Click here %
Elevated Work/Platform / Click here % / Crane / Click here %
Additional Activities:
Offsite Repair Work / Click here % / Repair for Customers / Click here %
Retail Sales of Equipment / Click here % / Third Party Training / Click here %
Signature & Declaration
Has the insured or any partner(s) or director(s) of the business:
- Had any insurance declined, or cancelled, proposal/application rejected, renewal refused, claim rejected, special conditions or excess imposed by an insurer?
- Ever been declared bankrupt?
- Ever been involved in a company or business which became insolvent or was subject to any form of insolvency administration?
- Been convicted of any criminal offence (other than minor traffic offences) within the last 5 years?
If you have answered yes to any of these questions, please provide details below:
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By completing and signing this application form, you declare that:
1.the disclosed information in this application is true an accurate in every respect and no information has been withheld which is likely to affect our decision about accepting this insurance;
2.If there is more than one insured and all have not signed this application, you have signed for and on their behalf;
3.you acknowledge we reserve the right to decline any application;
4.you acknowledge that if the applicant acquires, merges with or absorbs another practice or entity during the period of insurance, the insurer will require full details and may charge an additional premium;
5.you acknowledge that a signature on this application form does not provide insurance cover until the application is accepted in writing by the insurer.
Signature (Principal, Partner or Director) / Click here to enter text.
Date / 13/01/12 / Applicant’s Title / Click here to enter text.
Business Pack
Location Street Address: / Click here to enter text.
Suburb: / Click here to enter text. / Postcode: / Click here.
What is the age of the building? / Click here.
Wall Construction
Brick/Concrete / ☐ / Iron / ☐ / Timber/Fibro / ☐ / Asbestos / ☐
Roof Construction
Tile / ☐ / Iron / ☐ / Asbestos / ☐ / Concrete / ☐
Please indicate what fire protection you have installed:
Fire Sprinklers ☐ / Monitored Fire Alarm ☐ / Hosereels ☐ / Extinguishers ☐
Please indicate what security measures you have installed:
Deadlocks ☐ / Window Bars/Grills ☐ / Local Alarm ☐ / Monitored Alarm ☐
Is the Premises Fully enclosed by Fencing? / Yes ☐ / No ☐
Cover Required
Section 1: Business Property / Sum Insured
Buildings / $Click here.
Contents (Excluding Stock) / $Click here.
Stock (Excluding Hire Stock in Trade) / $Click here.
Removal of Debris / $Click here.
Section 2: Business Interruption / Sum Insured
Gross Profit (Turnover Less Cost of Goods Sold) / $Click here.
Additional Increased Cost of Working (automatic cover $50,000) / $Click here.
Claims preparation costs ( automatic cover $50,000) / $Click here.
Accounts Receivable / $Click here.
Indemnity Period / 6 Months ☐ / 12 Months ☐ / 18 Months ☐ / 24 Months ☐
Section 3: Theft / Sum Insured
Contents / $Click here.
Stock / $Click here.
Section 4: Money / Sum Insured
Blanket cover / $Click here.
Section 5: Employee Dishonesty / Sum Insured
$10,000 ☐ / $20,000 ☐ / Not Required ☐
Section 6: Machinery Breakdown / Sum Insured
Blanket Limit (any one loss, any one unit) / $Click here.
Please specify any items above the limit requested above:
Item Description / Click here to enter text. / $Click here.
Item Description / Click here to enter text. / $Click here.
Item Description / Click here to enter text. / $Click here.
Section 7: Electronic Equipment / Sum Insured
Blanket Limit (any one loss, any one unit) / $Click here.
Please specify any items above the limit requested above:
Item Description / Click here to enter text. / $Click here.
Item Description / Click here to enter text. / $Click here.
Item Description / Click here to enter text. / $Click here.
Section 9: Breakage of Glass / Replacement Value / Yes ☐ / No ☐
Additional Benefits / Standard Limit $7,500 / Nominate Increased Limit (If Required)
Section 10: General Property / Sum Insured
Blanket Limit (any One Loss, Any One Unit) / $Click here.
Please specify any items above the limit requested above:
Item Description / Click here to enter text. / $Click here.
Item Description / Click here to enter text. / $Click here.
Item Description / Click here to enter text. / $Click here.
Claims
Has the insured or any partner(s) or director(s) of the business had any claims in the last 5 years OR suffered any loss or damage that would have been covered by this proposed insurance policy? / Yes ☐ / No ☐
Date of Loss / Excess Applicable / Loss Amount / Description of Loss
Date. / Click here. / Click here. / Click here to enter text.
Date. / Click here. / Click here. / Click here to enter text.
Date. / Click here. / Click here. / Click here to enter text.
Date. / Click here. / Click here. / Click here to enter text.
Date. / Click here. / Click here. / Click here to enter text.
Liability
Limit of Liability / $10,000,000 ☐ / $20,000,000 ☐
- Is there an assigned OH&S Management system in place and/or assigned risk manager/OH&S representative?
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- Do you provide labor to operate/erect/dismantle equipment?
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Risk Management
Are all employees required to undergo formal safety training programs? / Yes ☐ / No ☐
Has the business been accredited/certified by relevant government bodies in OH&S and Quality Assurance? / Yes ☐ / No ☐
Are safe working instructions identified for all products? / Yes ☐ / No ☐
Are safe working instructions provided by the manufacturer? / Yes ☐ / No ☐
Do you provide any protective gear to the Hirer? / Yes ☐ / No ☐
Do you have any ‘tagging procedures’ in place for all hiring equipment? / Yes ☐ / No ☐
Are all staff trained in the operation of all available hire equipment? / Yes ☐ / No ☐
Do you perform any alterations, repairs on hiring equipment? / Yes ☐ / No ☐
Are their marked walkways around the premises for customer access at the site? / Yes ☐ / No ☐
Are all staff suitably qualified to inspect all equipment before hire? / Yes ☐ / No ☐
Is all servicing/maintenance of equipment performed on site? / Yes ☐ / No ☐
Business Activities
- Do you import or export any products?
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- Do you have a hold harmless agreement with all hire contracts?
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- Do you manufacture any products?
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- Do you have any involvement in the Oil, Gas, Electricity, Mining &/or Resource sectors?
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- Do you perform any waste management activities?
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Equipment Hire/Usage/Transportation
- Are hire items loaded into vehicles and secured for the hirer?
- Do you transport any equipment for the customer?
- Do you sell any used equipment?
- Do you promote mobile cranes for hire?
- If lifting devices are available for hire, are ‘Working Load Limits clearly indicated on all products?
- How often is electrical equipment tested (by qualified staff)?
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Scaffolding & Elevated Work Platforms (EWP)
- Is all EWP equipment inspected/ tested before hire?
- Are manuals and/or log books issued to all hirers with EWP’s?
- Is fall prevention harnesses supplied with EWP’s?
- Are any of the EWP’s older than 10 years?
- Do you tag/check all operator licenses before hire?
- Do you erect scaffolding for the hirer?
- Do you supply safety guidelines/instructions for the hirer?
- Are all maintenance and inspection records retained and documented?
Please advise of any additional details here:
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Party Hire/Equipment
- Do you adhere to Australian Standards for all party hire equipment?
- Do you pre-inspect all party hire equipment before use?
- Do you service and/or check all equipment before hire and is this documented?
- Do you perform repairs/alterations on all equipment?
- How often is electrical equipment tested (by qualified staff)?
- Are all tents/marquees fully checked before hire (including peg & pole tests)?
Claims
Has the insured or any partner(s) or director(s) of the business had any claims in the last 5 years OR suffered any loss or damage that would have been covered by this proposed insurance policy? / Yes ☐ / No ☐
Date of Loss / Excess Applied / Loss Amount / Description
Date. / Click here. / Click here. / Click here to enter text.
Date. / Click here. / Click here. / Click here to enter text.
Date. / Click here. / Click here. / Click here to enter text.
Date. / Click here. / Click here. / Click here to enter text.
Date. / Click here. / Click here. / Click here to enter text.
Hire Plant & Equipment
Section A: Please provide the split of your sum insured for the following items:
Agricultural Equipment / $Click here. / Catering Equipment / $Click here.
Cleaning Equipment / $Click here. / Computer Equipment & Electronics / $Click here.
Construction Equipment / $Click here. / Earthmoving Equipment / $Click here.
Landscaping Equipment / $Click here. / Lifting Equipment / $Click here.
Marquees/Dance Floors / $Click here. / Party Hire Equipment / $Click here.
Elevated Work/Platform / $Click here. / Cranes / $Click here.
Total: / $Click here.
NB: An itemized schedule of the items to be insured by this policy will also be required
Section B: Do you require Third Party Legal Liability?
(For registered items only) / Yes ☐ / No ☐
Will any of the items be working Underground or on Rails? / Yes ☐ / No ☐
Will any of the items be working in, on or over Water? / Yes ☐ / No ☐
Will any of the items be used in the following industries:
Mining, Power Stations, Aviation, Dams, Offshore Platforms, Explosives / Yes ☐ / No ☐
Will any of the items be used for demolition activities? / Yes ☐ / No ☐
Claims
Has the insured or any partner(s) or director(s) of the business had any claims in the last 5 years OR suffered any loss or damage that would have been covered by this proposed insurance policy? / Yes ☐ / No ☐
Date of Loss / Excess Applied / Loss Amount / Description
Date. / Click here. / Click here. / Click here to enter text.
Date. / Click here. / Click here. / Click here to enter text.
Date. / Click here. / Click here. / Click here to enter text.
Date. / Click here. / Click here. / Click here to enter text.
Date. / Click here. / Click here. / Click here to enter text.
PSC Underwriting
A division of Horsell International Pty Limited ABN 30 129 444 828 AFS Licence No. 235130 Page 1 of 8