proposal form - Pen Underwriting

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PROPOSAL FORM Tattoo Parlour Public Liability Insurance

Important Notices Please read these Important Notices before completing the Proposal. Your 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 be expected to know, is relevant to the insurer’s decision whether to accept the risk of the 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 of common knowledge;  that your insurer knows or, in the ordinary course of his business, ought to know;  as to which 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 his 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. Privacy Pen Underwriting handles your personal information with care and in accordance with the Privacy Act 1988 and the Australian Privacy Principles. We collect personal information about you to provide you with insurance and insurance related services. We may disclose your personal information to third parties for the purposes described in our Privacy Policy, including related entities, insurers, reinsurers, agents and service providers, some of whom may be located in the United Kingdom and India. By asking us to provide you with insurance and insurance related services, you consent to the collection, use and disclosure (including overseas disclosure) of your personal information for the purposes described in our Privacy Policy. Where you provide personal information about others, you represent to us that you have made them aware of that disclosure and of our Privacy Policy and that you have obtained their consent. If you do not consent to provide us with the personal information that we request, or withdraw your consent to the use and disclosure of your personal information at any stage, we may not be able to offer you the products or provide the services that you seek. For information about how to access and or correct the personal information we hold about you or if you have any concerns or complaints, ask us for a copy of our Privacy Policy or visit www.penunderwriting.com.au. Complaints Handling If you are dissatisfied with a decision Pen Underwriting makes, our service, the service of others we appoint to discuss insurance matters with you, or a claim settlement, we have an internal dispute resolution process to assist you. For further information, ask for a copy of our Complaints and Disputes Resolution Policy or visit www.penunderwriting.com.au. General Insurance Code of Practice Pen Underwriting and Underwriters at Lloyd’s proudly support the General Insurance Code of Practice. The purpose of the Code is to raise standards of practice and service in the general insurance industry. A copy of the Code can be obtained from www.codeofpractice.com.au or from us upon request. Further Information Your insurance broker can assist you to complete this Proposal. If you have any questions or need further information concerning your insurance, you should contact your insurance broker to assist you with your enquiry. You should direct all of your correspondence to Pen Underwriting through your insurance broker as he is your agent for this insurance.

Page 1 of 3

IMPORTANT NOTICE   

Please answer all questions in full. Where appropriate, tick the ‘Yes’ or ‘No’ box that best indicates your reply. If there is insufficient space provided, please provide further information on your letterhead. All attached documents form part of this Proposal.

This application is for

1.

New Business

Renewal - Policy Number (if known) is: .....................................................

YOUR DETAILS: Full Name: ....................................................................................................................................................................... Your ABN: ........................................................................................................................................................................ Trading Name: ................................................................................................................................................................. Interested Parties: ............................................................................................................................................................ What Interest do the above parties have: ........................................................................................................................ Business Description: ...................................................................................................................................................... Years in Operation:

This Business: ................................... years

Any Similar Business: ............................... years

What percentage of GST on Premium do you intend claiming as an Input Tax Credit? .............................................. % Are your books of account prepared by a public accountant each year?

Yes

No

Have you or any director/partner/manager of the business ever: a)

had insurance declined or cancelled?

Yes

No

b)

had an insurer refuse or not invite renewal?

Yes

No

c)

had any special conditions imposed on a policy of insurance?

Yes

No

d)

had a special excess imposed on a policy of insurance?

Yes

No

e)

had a claim rejected under a policy of insurance?

Yes

No

f)

been declared bankrupt or put into receivership or liquidation?

Yes

No

g)

been charged with or convicted of a criminal offence?

Yes

No

h)

Any other matters you should disclose (see ‘Your Duty of Disclosure’)?

Yes

No

Yes

No

If Yes to any of the above questions, please provide complete details on a separate piece of paper. 2.

YOUR CLAIM HISTORY In the last 5 years have you sustained loss or damage (insured or not) of a type against which insurance is now being sought? If Yes, please provide details: Date

3.

Insurer

Details

YOUR PREMISES Your Business Address:

......................................................................................................................................... .........................................................................................................................................

Construction of the building: Walls:

Brick/Concrete

Wood

Iron

Other

Roof:

Iron

Timber

Concrete

Other

Floors:

Timber

Concrete

Other

Tattoo Parlour Proposal Form v11.14 Page 2 of 3

4.

BUSINESS OPERATION DETAILS 4.1. Indemnity Limit required Public and Products Liability: 4.2. Annual Turnover:

$............................................................................................. any one occurrence $............................................................................................................................

4.3. Do you have any contractors working for you as a service?

Yes

No

If Yes, do you require them covered under this policy?

Yes

No

If Yes, please list names of Contractors and years of experience as a tattoo artist: ........................................................................................................................................................................ ........................................................................................................................................................................ ........................................................................................................................................................................ 4.4. Hours of Operation: ................................................................................................................................................. 4.5. Are instruments and equipment sterilised frequently?

Yes

No

4.6. Are new needles used for each session?

Yes

No

4.7. Is each client provided with written aftercare instructions?

Yes

No

4.8. Do you have all clients sign releases stating they are at least 18, understand the procedures and are not under the influence of drugs or alcohol?

Yes

No

4.9. Have you ever had any incidents involving disorderly persons?

Yes

No

4.10. Do you tattoo or pierce private areas of the body?

Yes

No

If Yes, a)

Are there any previous allegations of improper sexual conduct?

Yes

No

b)

Do you have private booths for discreet tattoos or piercings?

Yes

No

4.11. What brand of Ink do you use: ................................................................................................................................ ................................................................................................................................................................................ 4.12. Is the Ink made in Australia or imported from overseas?

Australian

Imported

If Imported, please advise origin of the Ink: .............................................................................................................

Declaration: I/We declare that: I/We am authorised by each of the Applicant(s) to sign this Proposal The statements in this Proposal are true and complete and no material information has been withheld I/We have read and understood the Important Notices accompanying this Proposal I/We have diligently made all necessary enquiries in order to comply with the duty of disclosure I/We have read the Pen Underwriting Privacy Statement on this Proposal and consent to the use, disclosure and obtaining of personal information about the insured for the purposes shown in the Privacy Statement Where I/We have provided information about another individual, that individual has been made aware of that fact and of the Pen Underwriting Privacy Statement I/We acknowledge that Pen Underwriting relies on the information and representations in this Proposal and otherwise made by me or on my behalf in relation to this insurance Except where indicated to the contrary, I/We understand that any statement made in this Proposal will be treated as a statement made by all persons to be insured I/We undertake to notify Pen Underwriting of any material alteration to the information contained in this Proposal prior to inception of the proposed insurance I/We understand that no insurance is in place until such time as Pen Underwriting has confirmed acceptance of the proposed insurance Signature/s: ....................................................................................................................

Date: .........................................

Name/s: ...........................................................................................................................

Title: .........................................

Tattoo Parlour Proposal Form v11.14 Page 3 of 3

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proposal form - Pen Underwriting

PROPOSAL FORM Tattoo Parlour Public Liability Insurance Important Notices Please read these Important Notices before completing the Proposal. Your Du...

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