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Insurance Rater

Insurance Application

Demo of Truck Insurance Application form version 0.1

Note: Applications filled out on this form are not valid and are just for testing and demonstration purposes.

Step 1 of 7 - Client Details

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Insured Name*

Title*
Name*
First Last
Contact Number*
Email*
Enter Email Confirm Email
Address*
This can be the business street address or home address.
Street Address City State Postcode Country

Occupation Details
General Carrier*
- yes
- no
Building Materials %
Please enter a value between 0 and 100.
Grains %
Please enter a value between 0 and 100.
Dry Foods %
Please enter a value between 0 and 100.
Machinery %
Please enter a value between 0 and 100.
Sand, Gravel Rock %
Please enter a value between 0 and 100.
Non Hazardous Liquds %
Please enter a value between 0 and 100.
General Non Hazardous %
Please enter a value between 0 and 100.
Scrap Metal %
Please enter a value between 0 and 100.
Dangerous goods %
Please enter a value between 0 and 100.
Containers %
Please enter a value between 0 and 100.
Fuel %
Please enter a value between 0 and 100.
Garbage %
Please enter a value between 0 and 100.
Other %
Please enter a value between 0 and 100.
Tobacco Products %
Please enter a value between 0 and 100.
Refrigerated Transport?*
- yes
- no
Refrigerated Food %
Please enter a value between 0 and 100.
Tow Truck / Vehicle Transport?*
- Yes
- No
Options
- Accident Recovery Option
- Breakdown Option
Cars %
Please enter a value between 0 and 100.
Machinery %
Please enter a value between 0 and 100.
Livestock*
Do you transport livestock?
- Yes
- No
Options
- Horse Transport Option
Number of Horses?
Please enter a value between 0 and 100.
Livestock %
Please enter a value between 0 and 100.
Furniture Removals*
- Are you a furniture removalist?
- No
Furniture %
Please enter a value between 0 and 100.
Logging/Timber*
Logging only relates to timber harvesting/logging operations and deliveries (unmilled logs only). Timber relates to sawn/dressed construction timbers.
- Yes
- No
Logs %
Please enter a value between 0 and 100.
Sawn Timber %
Please enter a value between 0 and 100.
Dangerous Goods*
Any material carried in sufficent volume to require dangerous goods placards to be displayed.
- Yes
- No
Class
If more than one class or type please list all.
Volume
Bulk Tanker, Containerised, ISO tanks etc.
Type
Hazardous Goods %
Please enter a value between 0 and 100.
Fuel %
Please enter a value between 0 and 100.
Concrete Delivery*
Delivery of wet mix concrete
- Yes
- No
Concrete %*
Please enter a value between 0 and 100.
Water Tanker*
Delivey of potable/non potable water as well as spraying of water for dust suppression or enviromental reasons.
- Yes
- No
Distribution*
Includes Small goods, Milk, Juice, Newspapers, etc.
- Yes
- No

Occupation Details continued..
Turnover
Freight Transport Income*
Income from transport activities.
Please enter a value between 0 and 200000000.
Sales Income*
Income from the sale of goods you retail/wholesale.
Please enter a value between 0 and 200000000.
Other Income*
Income from any other source excluding transport or sales. Can include mechanical repairs, rental charges for equipment etc.
- Yes
- No
Other Income Amount*
Please enter a value between 0 and 200000000.
Other Income Source*
Please list what your other income relates to.
Staffing
Number of working Directors*
Please enter a value between 0 and 99.
Number of PAYG staff*
Number of staff employed (non ABN holders)
Please enter a value between 0 and 999.
Annual Wages Amount*
Annual wages estimated to be paid in coming 12 months.
Please enter a value between 0 and 200000000.
Number of Contractors Engaged*
Number of contractors engaged under ABN. This can include drivers etc.
Please enter a value between 0 and 999.
Activities of Contractors
Please list what work your contractors perform.
Number of Sub-Contractors Engaged*
Please enter a value between 0 and 999.
Activities of Sub-Contractors
Number of personnel sourced from labour hire firm.*
Labour hire firm sourced staff.
Please enter a value between 0 and 999.
Activities of Labour Hire Personnel
Activities labour hire staff undertake.
Business
If you engage Contractors or Labour Hire Personnel, are they required to carry their own Public Liability and Workers Compensation Insurance
- Yes
- No
Years in Business*
How long has the business been operating, include if business has changed/updated legal entities but continued the same despite entity changes. Changes could include going from a sole trader to company or setting up new trusts etc.
Please enter a value between 0 and 99.
Are You A Prime Contractor?*
- Yes
- No
Are You A Sub-Contractor?*
- Yes
- No
Will you be working/conducting activities underground in mining, excavation, etc*
- Yes
- No
Will you be working within the boundaries of an Airport*
This relates to restricted area access work airside.
- Yes
- No

Goods In Transit
Limit of Indemnity*
Maximum sum insured for items being transported at any one time.
Radius from base of operations*
All cover will be Australia wide, just need to know typical radius
In the last 5 years have you ever claimed on a Goods in Transit Policy*
- Yes
- No
Date of Loss
Amount Paid
Please enter a value between 0 and 999999999999.
Details
Do you operate under a valid consignment note*
- Yes
- No

Liability Details
History
Limit of Indemnity*
Have you assumed liability under any contract by way of hold harmless causes, indemnities, waiver of subrogation or rights of recourse against any third party*
- Yes
- No
In the last 5 years have ever claimed on a liability policy*
- Yes
- No
Date of Loss
Amount Paid
Please enter a value between 0 and 999999999999.
Details
Dangerous Goods / Livestock*
- Yes
- No
Provide full details
Dangerous Goods / Hazardous Goods Storage control procedures*
Waste Management control Procedures*

Declaration
Have you had any insurance declined or cancelled?*
- Yes
- No
Have you ever had an insurer refuse or no invite renewal?*
- Yes
- No
Have you ever had any special conditions imposed on a policy of insurance?*
- Yes
- No
Have you ever had a special excess imposed on a policy of insurance?
- Yes
- No
Have you ever had a claim rejected under a policy of insurance?*
- Yes
- No
Have you ever been declared Bankrupt or put into receivership or liquidation?*
- Yes
- No
Have you ever been charged with or convicted of a criminal offense?*
- Yes
- No
If yes to any of the above questions please provide complete details*

Duty of Disclosure
You are the listed insured, or authorised by the listed insured to organise insurance on their behalf*
- Yes
- No
If there is more than on insured, you are authorised to organise insurance on their behalf, and that if you disclosed personal information about any insured person or any other person, you have made them or will make them aware that you have provided their personal information to us and the types of third parties we may provide it to, the relevant purposes we and third parties will use it for, and how the insured person or other person can access it?*
- Yes
- No
The disclosed information is true and correct?*
- Yes
- No
You have read the above duty of disclosure and are aware that should you not fully and truthfully disclose all relevant information, an insurer may decline a claim or void a policy?*
- Yes
- No
You consent that any personal information you provide to Truck Insurance HQ/NAS Insurance Brokers will be collected, stored, used and disclosed in accordance with our Privacy Policy located at http://www.nasinsurance.com.au/PrivacyPolicy.aspx. We may provide your information to insurance companies and other intermediaries in order to provide insurance quotes and offer insurance terms to you or the companies that deal with your insurance claim (such as loss assessors and claims staff).*
- Yes
- No
You are aware that no insurance is in force until such time that the insurer accepts this proposal of insurance and that this proposal of insurance and that this application form will form the basis of the insurance contract between the insured and the insurer?*
- Yes
- No
You acknowledge that any premiums stated are indicative only and subject to insurer confirmation, and may change based on the information you have provided.*
- Yes
- No
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Your Name *
Your Email *
Phone/Mobile *
State *
Message *

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