Guest Group Accident Proposal Form THE PROPOSER Names(s) in full (Indicate if incorporated Pty Ltd or partnership) Tax Status Registered Business ABN Input Tax Credit Yes □ No □ % Contact Person Contact Numbers Phone (Business) (Private) (Mobile) Fax Email Other Interested Persons (i.e. Mortgagees) Building Owner Postal Address Postcode . Period of Insurance From / / to / / at 4.00pm Description of Business PREVIOUS HISTORY Have you, your partners or any Directors of the Business, in the last 5 years made any claims Yes □ No □ against an insurer for loss or damage? If ‘Yes’ please provide full details including name of insurer, dates, description and amounts (if ‘No’ write ‘nil’): Have you, your partners or any Directors of the Business, had any insurance declined, cancelled, proposal/application rejected, renewal refused, Yes □ No □ claim rejected, special conditions or excess imposed by an insurer? suffered any loss or damage which would be covered by the proposed insurance Yes □ No □ policy? Yes □ No □ ever been declared bankrupt? ever been involved in a company or business which became insolvent or subject to any Yes □ No □ form of insolvency administration (e.g. Liquidation or receivership)? Yes □ No □ ever been convicted of any criminal offence (other than minor traffic convictions) ? ever been liable for any civil offence or pecuniary? Yes □ No □ If Yes for any of the above questions please attach details:-
Guest Group Accident Proposal Form THE PROPOSER Names(s) in full (Indicate if incorporated Pty Ltd or partnership) Tax Status Registered Business Yes □ No □ ABN Input Tax Credit % Contact Person Contact Numbers Phone (Business) (Private) (Mobile) Fax Email Other Interested Persons (i.e. Mortgagees) Building Owner Postal Address Postcode . Period of Insurance From / / to / / at 4.00pm Description of Business PREVIOUS HISTORY Have you, your partners or any Directors of the Business, in the last 5 years made any claims against an insurer for loss or damage? Yes □ No □ If ‘Yes’ please provide full details including name of insurer, dates, description and amounts (if ‘No’ write ‘nil’): Have you, your partners or any Directors of the Business, had any insurance declined, cancelled, proposal/application rejected, renewal refused, claim rejected, special conditions or excess imposed by an insurer? suffered any loss or damage which would be covered by the proposed insurance policy? ever been declared bankrupt? ever been involved in a company or business which became insolvent or subject to any form of insolvency administration (e.g. Liquidation or receivership)? ever been convicted of any criminal offence (other than minor traffic convictions) ? ever been liable for any civil offence or pecuniary? If Yes for any of the above questions please attach details:- Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □ Yes □ No □
Group-Guests-PA-Declaration-v3.docx