Level 29, Chifley Tower, 2 Chifley Square, Sydney 2000

PO Box 6542 Baulkham Hills Bus. Centre 2153

Tel: 1300 880 494 Fax: (02) 9225 9943
E-mail: cr m1@crmbrokers.com.au

CRM LIABILITY INSURANCE QUESTIONNAIRE 

Applicant(s)
Name of Applicant (include ‘Trading As’ if applicable): _____________________________________________

Postal Address: ___________________________________________________________________________

Business or occupation: _____________________________________________________________________

Interested Parties
Are any other parties interested in the insurance for which you are applying? Yes No

(if yes) Name of interested party: _____________________________________________________________

Address: _______________________________________________________________Postcode: _________

Type of interest: ___________________________________________________________________________

1. Fully describe the business activities of the Applicant and of each subsidiary company (and their subsidiaries)
under the control of the Applicant (provide attachment if space is insufficient).

Name of company/business: _________________________________________________________________

Business activities at own premises: ___________________________________________________________

Business activities away from own premises: ____________________________________________________

Proportion away from own premises: __________________________________________________________

Location address(es) including Postcode(s): _____________________________________________________

Premises owned or leased: __________________________________________________________________

Date operations commenced (even if not then owned by Applicant): __________________________________

133 Alexander St
Crows Nest NSW 2065
•
Level 3 / 67-69 Phillip St
Parramatta NSW 2150
•
Level 8 / 350 Collins St
Melbourne Vic 3000
•
CRM Brokers Pty Ltd ACN 088 887 138
ABN 68 088 887 138
AFS Licence 246622
 Level 29, Chifley Tower, 2 Chifley Square, Sydney 2000
PO Box 6542 Baulkham Hills Bus. Centre 2153
Tel: 1300 880 494 Fax: (02) 9225 9943
E-mail: cr m1@crmbrokers.com.au

If less than 3 years ago have you any previous experience in operating this business? Yes No

If yes, how many years: ______________

2. Are you applying to insure liability as a property owner but not as an occupier? Yes No
If yes, state occupancy of building(s):
_____________________________________________________

Size in square metres: ___________________________Age of building(s): ______________________

Construction type/materials: ____________________________________________________________

Details of fire protection (sprinklers, etc.) __________________________________________________

__________________________________________________________________________________

Number of: Lifts/Elevators: _____________________ Escalators/Travelators: _______________________

3. State the following:

Number of partners actively engaged in the business: ____________________________

Number of buildings owned by the business: ___________________________________

Number of buildings occupied by the business: _________________________________

$ Actual past year $ Estimate next

year
Annual turnover:

Value of annual sales:

Value of gross rentals:

133 Alexander St
Crows Nest NSW 2065
•
Level 3 / 67-69 Phillip St
Parramatta NSW 2150
•
Level 8 / 350 Collins St
Melbourne Vic 3000
•
CRM Brokers Pty Ltd ACN 088 887 138
ABN 68 088 887 138
AFS Licence 246622
 Level 29, Chifley Tower, 2 Chifley Square, Sydney 2000
PO Box 6542 Baulkham Hills Bus. Centre 2153
Tel: 1300 880 494 Fax: (02) 9225 9943
E-mail: cr m1@crmbrokers.com.au

4. State the annual salaries and wages and number of staff in each category.
Salaries and wages Number of staff
(a) Managerial, clerical and sales: $
(b) Manufacturing: $
(c) Installation, repairs and $
maintenance:
(d) Contractors and subcontractors: $
(e) Other (specify) $

5. Have you signed away, or will you sign away, any rights you may have had to recover damages from any
person (sometimes known as ‘hold harmless’ agreements)? Yes No

If yes, state full details:

____________________________________________________________________________________

Public Liability

Limit of Indemnity
$5,000,000 $10,000,000 Other – Please specify $

6. Do you hire-in or hire-out equipment? Yes No - If yes, please attach a copy of the hiring
agreement(s) and state the following:

Hire-in charges Hire-out income Type(s) of equipment

133 Alexander St
Crows Nest NSW 2065
•
Level 3 / 67-69 Phillip St
Parramatta NSW 2150
•
Level 8 / 350 Collins St
Melbourne Vic 3000
•
CRM Brokers Pty Ltd ACN 088 887 138
ABN 68 088 887 138
AFS Licence 246622
 Level 29, Chifley Tower, 2 Chifley Square, Sydney 2000
PO Box 6542 Baulkham Hills Bus. Centre 2153
Tel: 1300 880 494 Fax: (02) 9225 9943
E-mail: cr m1@crmbrokers.com.au

7. Do you engage contractors, subcontractors in your business? Yes No If yes:

a) Do you ensure that contractors and subcontractors have their own liability insurance? Yes No

b) Do you require insurance to cover your liability for their actions? Yes No

c) What amounts were paid during the last twelve months to contractors or subcontractors for:
* Labour and Materials? (if in more than one State, show each separately) $
* Labour only? (if in more than one State, show each separately) $

d) What amounts were paid during the last twelve months to labour hire firms? (if in more than one State,
show each separately) $

e) What type(s) of work does staff from labour hire firms perform for you? __________________________

______________________________________________________________________________________

8. Do you, in the course of your business, engage in welding operations or use LPG or butane or similar for
heating or cutting, either directly or through a contractor or subcontractor? Yes No

If yes, are all persons required to comply with AS1674 SAA Cutting and Welding Safety Code? Yes No

9. Are your business activities subject to legislative regulations (e.g. Environmental Protection Authority,
Hazardous Chemicals)? Yes No If yes, Detail any exemptions and/or history of non-compliance:

_______________________________________________________________________________________

133 Alexander St
Crows Nest NSW 2065
•
Level 3 / 67-69 Phillip St
Parramatta NSW 2150
•
Level 8 / 350 Collins St
Melbourne Vic 3000
•
CRM Brokers Pty Ltd ACN 088 887 138
ABN 68 088 887 138
AFS Licence 246622
 Level 29, Chifley Tower, 2 Chifley Square, Sydney 2000
PO Box 6542 Baulkham Hills Bus. Centre 2153
Tel: 1300 880 494 Fax: (02) 9225 9943
E-mail: cr m1@crmbrokers.com.au

10. Do you use any steam pressure vessels or air compressors which require a certificate under the terms of any
statute or regulation? Yes No If Yes, State numbers of such pressure vessels and compressors and
maximum operating pressures.

_______________________________________________________________________________________

11. Do you use any hoists or cranes? Yes No If Yes, State number(s) and type(s) of hoists
and/or cranes. ____________________________________________________________________________

12. Are there any Vehicles, or plant or attachments to Vehicles, which you use as a working tool.
Yes No

13. Are there any goods, not owned by you, left in your possession or control from time to time?
Yes No If Yes, State maximum value at any one time $ Type(s) of goods

14. Is any manual work performed outside Australia? Yes No If Yes, State the nature of the work and
the countries or territories: __________________________________________________________________

Products Liability

Limit of Indemnity
$5,000,000 $10,000,000 Other – Please specify $

15. (a) Show the percentage of turnover derived by the business as:

Manufacturer Importer Wholesaler/Distributor Retailer Exporter

% % % % %

(b) State the countries or territories to or from which goods or Products are:

133 Alexander St
Crows Nest NSW 2065
•
Level 3 / 67-69 Phillip St
Parramatta NSW 2150
•
Level 8 / 350 Collins St
Melbourne Vic 3000
•
CRM Brokers Pty Ltd ACN 088 887 138
ABN 68 088 887 138
AFS Licence 246622
 Level 29, Chifley Tower, 2 Chifley Square, Sydney 2000
PO Box 6542 Baulkham Hills Bus. Centre 2153
Tel: 1300 880 494 Fax: (02) 9225 9943
E-mail: cr m1@crmbrokers.com.au

Exported
_____________________________________________________________
Imported
_____________________________________________________________

(c) For Products exported to North America (USA, Canada and states or territories administered by them),
describe the Products and state the turnover derived from exports of each of them to North America.

______________________________________________________________________________________

(d) Do you or your agent operate any premises or plant in North America for the manufacturing, processing,
treating, distribution or storage of Products? Yes No If yes, Give details:

______________________________________________________________________________________

16. (a) List the Products and indicate the percentage of turnover represented by each.

_______________________________________________________________________________________

_______________________________________________________________________________________

(b) What Products other than those listed above have the Applicant and subsidiaries handled in the past?

_______________________________________________________________________________________

_______________________________________________________________________________________

17. Which of the Products were not designed or formulated by you, or by your own staff, and who designed
or formulated them?

_______________________________________________________________________________________

133 Alexander St
Crows Nest NSW 2065
•
Level 3 / 67-69 Phillip St
Parramatta NSW 2150
•
Level 8 / 350 Collins St
Melbourne Vic 3000
•
CRM Brokers Pty Ltd ACN 088 887 138
ABN 68 088 887 138
AFS Licence 246622
 Level 29, Chifley Tower, 2 Chifley Square, Sydney 2000
PO Box 6542 Baulkham Hills Bus. Centre 2153
Tel: 1300 880 494 Fax: (02) 9225 9943
E-mail: cr m1@crmbrokers.com.au

_______________________________________________________________________________________

18. Do you install or apply your own Products? Yes No If Yes, What percentage of turnover
relates to this activity? %

19. Are the finished Products subject to any Australian Standards Association codes or relevant international
codes? Yes No If Yes, Give details:

_______________________________________________________________________________________

20. Will any Products be introduced to your range in the next 12 months?
Yes No If Yes, Give details:

_______________________________________________________________________________________

21. What methods of quality control are adopted? ______________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

22. What records are kept relating to supply of materials, manufacturing processes, incident reports, batch
numbering etc., and for what period are they kept?
_______________________________________________________________________________________

_______________________________________________________________________________________

_______________________________________________________________________________________

General

133 Alexander St
Crows Nest NSW 2065
•
Level 3 / 67-69 Phillip St
Parramatta NSW 2150
•
Level 8 / 350 Collins St
Melbourne Vic 3000
•
CRM Brokers Pty Ltd ACN 088 887 138
ABN 68 088 887 138
AFS Licence 246622
 Level 29, Chifley Tower, 2 Chifley Square, Sydney 2000
PO Box 6542 Baulkham Hills Bus. Centre 2153
Tel: 1300 880 494 Fax: (02) 9225 9943
E-mail: cr m1@crmbrokers.com.au

23. (a) Have you ever caused injury or damage, or had any claims made against you from any contingency
against which you are applying to insure? Yes No If Yes, please give the following details:

Details of injury or damage Date Name of insurance company Amount claimed

$
$
$

(b) Are you aware of any past or ongoing processes, conditions, circumstances or activities of the Business which
might give rise to claims against you in future for Personal Injury or Damage to Property (including anything that
may cause irritation, contamination or pollution). Yes No If Yes, Give details: ________________

_______________________________________________________________________________________

_______________________________________________________________________________________

24. Has any insurer declined an application or a claim from you or cancelled or refused to renew your policy or
required special terms to insure you? Yes No If yes, please give following details:

Date / / Name of insurer:

________________________________________________________________________________________

Details of action taken by insurer: _____________________________________________________________

25. Have you (or any directors) been charged with, or convicted of, a criminal offence during the past 10 years?

Yes No If yes, Date / / Offence __________________ Penalty or fine _________________

26. Do you hold any other type of insurance with us?

Yes No If yes, state the types of insurance ______________________________________________

133 Alexander St
Crows Nest NSW 2065
•
Level 3 / 67-69 Phillip St
Parramatta NSW 2150
•
Level 8 / 350 Collins St
Melbourne Vic 3000
•
CRM Brokers Pty Ltd ACN 088 887 138
ABN 68 088 887 138
AFS Licence 246622
 Level 29, Chifley Tower, 2 Chifley Square, Sydney 2000
PO Box 6542 Baulkham Hills Bus. Centre 2153
Tel: 1300 880 494 Fax: (02) 9225 9943
E-mail: cr m1@crmbrokers.com.au

_________________________________________________________________________________________

27. Are there any other relevant facts relating to the risk to be insured which you should disclose to enable a true
assessment of your application to be made? Yes No If yes, please state the facts _____________

_______________________________________________________________________________________

_______________________________________________________________________________________

 If you have any questions regarding the information to be provided on this form, please phone Damien Coorey
direct on 1300 880 494.

Please fax the completed questionnaire to: (02) 9225 9943 or e-mail your reply to: crm1@crmbrokers.com.au

or mail to: Damien Coorey

CRM Brokers
PO Box 6542 Baulkham Hills Business Centre NSW 2153

133 Alexander St
Crows Nest NSW 2065
•
Level 3 / 67-69 Phillip St
Parramatta NSW 2150
•
Level 8 / 350 Collins St
Melbourne Vic 3000
•
CRM Brokers Pty Ltd ACN 088 887 138
ABN 68 088 887 138
AFS Licence 246622