Products Liability Proposal




The completion of this form is to enable Us to establish the nature of the proposers  operations, the extent of cover required, the conditions that are in existence and the rules and the procedures which will apply during the currency of the proposed insurance.

The completion and/or signing of this form does not bind the proposer to the making of a contract of insurance.  However, should such a contract be made then the information contained herein shall constitute a part of that contract.  Alterations and/or variations of any of the answers given to any of the questions in this proposal form can only be made with the prior advice to, and the approval of Us.


Full Name(s) to be Insured
Company Name
Tax Status
Registered Business
Contact Details
Phone No.
Mobile No.
Fax No.
Email Address
Postal Address
Period of Proposed Insurance
Current Insurer/Policy Expiry Date Limit of Indemnity Last Year’s Premium
How many years of experience in the Security Industry?
When was this business established?
What is the company’s Master License Number
Membership Body:
Describe all security checks undertaken for all new staff (Attach details if more space is required)
Total Annual Payroll $
Total Payments to Sub Contractors $
Percentage of turnover per state
SA %
NT %
WA %
Actual Turnover (previous year) $
Estimated Turnover (current year) $
Number of Fulltime employees
Number of Principals
Number of licensed Security Guards
Are you represented outside of Australia?
Limit of Indemnity Required?
Is Errors & Omissions Cover Required?
Is Loss of Keys Cover Required?
Is Cover for Cash Required?
Excess Options (minimum $2,500 standard excess, $10,000 Crowd Control) Discounts apply for voluntary excess.
WORK UNDERTAKEN % of Total Annual Turnover % of Turnover Sub-Contracted
Mobile Patrols/Static Guarding
Alarm Response
Cash in Transit (CIT)
Traffic Control
Debt Collector
Private Investigator
Alarm Monitoring
Security Consultant
Alarm Products Design/Alteration
Alarm Installation/Service & Maintenance – Non Residential
Alarm Installation/Service & Maintenance – Residential
Crowd Control (ie. Hotels, Events, etc.)
Security Trainers
Airport Security
Other (Please describe)
Important Notice
LICENSING For insurance coverage to be valid, the Insured must fully comply with all relevant statutory licensing requirements applicable to activities performed
WEAPONS AND PROTECTION EQUIPMENTS For insurance coverage to be valid, the Insured must comply with all relevant statutory requirements applicable to the use, storage, and otherwise of all equipment used, which includes Firearms, Dogs, Batons, etc.
TRANING For insurance coverage to be valid, all personnel must have achieved all relevant statutory levels of training applicable to the activities performed.
Do you use guard Dogs ?
How many ?
Do you use guns ?
How many guns do you use ?
Duties Performed
Will staff be required to wear or carry any of the following whilst on duty:
Other Protection Equipment Weapons
Provide Details
CARE, CUSTODY OR CONTROL (Property in your Physical or legal Control other than Cash & Keys ) – NEGLIGENCE COVER ONLY
Do you require cover for property of others in your care, custody or control?
What limit of indemnity do you require?
What is the total value of such property at all locations?
What is the maximum value of any one item?
Please provide a brief description of such property:
Do you assume liability under contract or hold others harmless (other than lease liability)?
Provide Details
Over the last five years, has the Insured experienced any incidents or losses (including claims losses, uninsured losses, reported possible losses or any unreported incidents that could become a loss) that would have been covered under this proposed insurance?
Attach Details
Have you or any of your Directors, Partners, Employees or Sub-contractor’s ever been charged with a criminal offence?
Has the Insured ever had any:
Insurance declined or cancelled?
Renewal refused?
Special conditions imposed?
Increased excess imposed?
Claims denied for this class of insurance?
If “YES” to any of the above, please provide details

• Understand the terms, limitations and exclusions as described in this proposal
• Have complied with the requirements of the Statutory Notice and the Important Notices shown on this Proposal.
• Declare that the information provided in the Proposal is true and correct.
• Acknowledge you reserve the right to decline any application
“I acknowledge that I have carefully read and understand every part of this proposal which was filled in by someone other than me. I further acknowledge that each such part is true and correct and is to be taken as having been filled out by me.”
Where you install Security Systems, please complete the following:
Are components to the systems manufactured or assembled by you?
If “Yes”, where such Products are manufactured/assembled by you under License, please provide copies of the Licence Agreements and specify the Products
Are the components to the system manufactured by others?
Where such Products are manufactured/assembled by others under Licence from You, please provide copies of the Licence Agreements and specify the Products
Do you design any of the systems, or components thereof?
If “Yes”, do you operate a Research and Development Department?
If “Yes”, please provide relevant details and qualifications of all personnel
Table 1 - Please provide below details of all Products manufactures, assembled, sold, supplied, serviced, treated or altered by you, together with Anticipated Failure Rate and Estimated Turnover for the forthcoming twelve months.
Description of Product Anticipated Failure Rate Estimated Annual Turnover
Table 2 – Products manufactured/assembled by you – no design:
Description of Product Anticipated Failure Rate Estimated Annual Turnover
Table 3 – Products sold, supplied or distributed by you – no design or manufacture/assembly:
Description of Product Anticipated Failure Rate Estimated Annual Turnover
Table 4 – If any new Products, not detailed above, are contemplated by you during the next twelve months, please provide details, and advise which category of Tables 1, 2 or 3 above applies:
Description of Product Category Estimated Annual Turnover
Table 5 – If you export any Products please provide details below. “Representation” in the Country means Branch, Subsidiary Company, Agency etc.:
Description of Product Country of Destination Representation Estimated Annual Turnover
Table 6 -
1. The fees earned where you provide only design or advice services ie. You do not undertake any installation. $
2. The turnover where you install and the system design is not provided by others. $
3. The turnover where you install and the system design is provided by others. $
Where, by your presence, you modify the behaviour of persons in or about public places to ensure safety of all persons in or about the place, please complete the following:
Please provide full details of:
Types of venues (eg venues/licensed Clubs/hotels/nightclubs) Duties of your employees % of Crowd Control Turnover
Do you have in place strict and documented site operating procedures?
If “Yes”, are all your relevant employees trained in relation to the site operating procedures?
Are employees re-trained every 12 months?
What are the minimum numbers of security personnel you provide onsite for the following types of premises:
Licensed Premises
Registered Clubs
Concert (entrance)
Concert (per 100 patrons
Hotels (max 50 patrons)
Hotels (each add’l 100 patrons)
Nightclubs/Discos (entrance)
Nightclubs/Discos (per 50 patrons)
Venue (entrance)
Venue (per 100 patrons)
Non-licensed Premises Per 100 patrons
Per 100 patrons
Cash In Transit
1. How many carries per week?
2. What will be the maximum carry? $
3. What is the average carry limit? $
4. For what transit limit (any one vehicle carry) is cover required? $
5. What will be the maximum pavement limit for which cover is required? $
6. What are the total values exposed at your premises?
a) During Business Hours (Hold-up): $
b) Outside Business Hours (In locked safe/vaults): $
7. What was the annual aggregate carry for the past 12 months? $
8. What is the estimated annual aggregate carry for the next 12 months? $
9. Estimated annual revenue/income for the next 12 months? $
10. Actual annual revenue/income for the past 12 months? $
11. Estimated Payments to Sub-Contractors $
12. Actual Payments to Sub-Contractors $
13. How many Soft Skin vehicles are used?
14. How many Armoured vehicles are used?
Please provide details of vehicles:
Description (make, model) Type of Security installed

Proposer Signature:
Date of Signing:

“I acknowledge that I have carefully read and understand every part of this proposal which was filled in by someone other than me. I further acknowledge that each such part is true and correct and is to be taken as having been filled out by me.”


The Proposer declares and warrants that after full and reasonable enquiry and to the best of his/her knowledge and belief all statements and particulars contained in this Proposal Form and (if applicable) addenda hereto are true and that no information whatsoever has been withheld which might increase the risk of the Underwriters or influence the acceptance of this Proposal Form and that should the above particulars alter in any way confirms that he/she will advise the Underwriters as soon as is practicable. The Proposer further declares and warrants that he/she has been duly authorised by the Directors and Officers and the Company to act as their agent in respect of all matters of any nature or kind relating to or affecting this Proposal Form and the Policy. The Proposer understands that failure to disclose any material facts which would be likely to influence the acceptance and assessment of the Proposal Form may result in the Underwriters refusing to provide indemnity or voiding the Policy in every respect. The Proposer hereby agrees and accepts that this Proposal Form and (if applicable) addenda hereto shall be the basis of the contract of insurance if entered into. The Underwriters are hereby authorised, at their absolute discretion, to make any investigation and enquiry in connection with regard to this Proposal as they deem necessary.

FOR AND ON BEHALF OF (Name of Company)
Position *

* Should be the Chairman, Managing Director or Chief Executive of the Company

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