Public Liability

1. Are any workers involved in manual works in connection with installation, erection, repair, maintenance, testing, demolition or construction outside insured premises

   please select Yes No

2. Are any workers involved in works at great heights (above 30 feet above floor or ground level)

   please select Yes No

3. Are any workers involved in works involving explosives, dangerous or toxic chemicals

   please select Yes No

4. Are any workers involved in excavation works, work in manholes or tunnels

   please select Yes No

5. Are any workers involved in excavation works, work in manholes or tunnels or any similarly activities

   please select Yes No

6. Are any workers involved in using heavy industrial machines that involve cutting ,pressing, grinding etc?

   please select Yes No

7. Are any workers involved in lifting or hoisting operations, especially in public areas

   please select Yes No

8. Do you undertake any work away from your premises?

   please select Yes No

   If yes, Give details

9. Does your business create any trade waste?

   please select Yes No

   If yes, please give details of waste and methods of disposal

10. Are any workers required to work onboard vessels

    please select Yes No

    If yes, what is the maximum no. of employees on board any vessel any one time

11. Will there be any diving &/or related underwater activities pertaining to your business?

    please select Yes No

12. Please provide details of any Hazardous Goods that are stored at your premises

13. Do you employ the services of contractors, sub-contractors

    please select Yes No

    If yes to any, are they required to carry their own Public/product Liability Insurance

    please select Yes No

14. Is there any insurance in force covering the same exposure for the same period of insurance being proposed

    please select Yes No

    If yes, what is the maximum no. of employees on board any vessel any one time

    Name of Insurer
    Limit of Indemnity

15. Has any Insurance Company ever refused your Public/product Liability Insurance Proposal or refused to renew your Policy

    please select Yes No

16. Has your insurance been cancelled solely or in part due to a breach of premium payment warranty in the last 12 months

    please select Yes No

PRODUCT LIABILITY

1. Please input a tabled list with the following headers:

   Attach any brochures or other related material for product

   1. Product

   2. Intended Use

   3. Manufacture Turnover

   4. Source country (if Imported)

   Input all product brochures

2. Do you manufacture, construct, erect, install, repair, service, treat, sell, supply or distribute any products

   please select Yes No

3. Please provide details of quality control procedures in place

4. Are your products subject to any Standards

   please select Yes No

   if yes, give details

5. Are you or is your product required to be compliant with any other industry standard or regulation

   please select Yes No

6. Period of Cover: From

   To

7. please a tabled list with the following headers

   1. Year

   2. Insurer

   3. Claimant

   4. Nature of Problem

   5. Amount Paid/Outstanding