Commercial Property Owners Insurance
Proposal Form
Protecting and supporting your community
Page 2
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
Important notices
Your duty of disclosure
Before you enter into a contract of general insurance with Ansvar
Insurance Limited (‘Ansvar’ or ‘us’ or ‘we’), you have a duty under the
Insurance Contracts Act 1984 to disclose to us every matter that you
know, or could reasonably be expected to know, is relevant to our
decision to accept the risk of insurance and, if so, on what terms.
You have the same duty to disclose these matters to us before you
renew, extend, vary or reinstate a contract of general insurance.
Your duty, however, does not require disclosure of any matter:
a. that diminishes the risk to be undertaken by us; or
b. that is of common knowledge; or
c. that we know or, in the ordinary course of our business, ought
to know;
d. as to which compliance with your duty is waived by us.
Your duty of disclosure continues after this proposal form has been
completed up until the contract of insurance is entered into.
Non Disclosure
If you fail to comply with your duty of disclosure, we may be entitled
to reduce our liability under the policy in respect of a claim or may
cancel the contract.
If your non-disclosure is fraudulent, we may also have the option of
avoiding the contract from its beginning.
Change to circumstances
You should advise Ansvar as soon as practicable of any material
change to the organisation insured and any of its subsidiaries and
controlled entities as disclosed in this proposal form.
Waiver of rights
If you have agreed not to seek compensation from another person
who is liable to compensate you for any loss, damage or liability
which would have been covered by this policy, we will not cover
you under this policy for that loss, damage or liability other than to
the extent provided under any Section of this policy or agreed by
us in writing.
Privacy Statement
Ansvar places the highest priority on providing prompt, ecient
and friendly service including the protection of your privacy.
We collect your personal information to provide you with general
insurance products. The information we collect is used to assist us
to provide you with our general insurance products, to manage our
relationship with you and to assess and process claims. We will not
be able to supply you our policy if you do not provide us with your
personal information. The information is generally collected from
you when you are applying for or enquiring about our insurance
products or when making a claim.
At times we rely on third party suppliers (agents, lawyers, other
insurance companies, assessors, investigators, loss adjusters,
market research and mailing houses) to perform specialised
activities for us. Your personal information may be provided to
them so that they can carry out their agreed activities. They are
bound by condentiality and non-disclosure agreements and are
prohibited from using the information for any other purpose.
These service providers are aware of their obligations under the
Privacy Act. We are unlikely to provide your personal information
to overseas recipients.
Our Privacy Policy includes further information about how
we handle your personal information including how you can
access and correct your information or make a privacy related
complaint. For more information please visit our website:
www.ansvar.com.au/privacy/ or you can contact one of our oces.
Code of Practice
As a signatory to the General Insurance Code of Practice (the “Code”),
we are committed to raising standards of service to our customers.
This voluntary code sets out the minimum standards we will uphold
in the services we provide to you. You can obtain more information
on the Code and how it assists you by contacting us.
Contact us
The registered oce of Ansvar is Level 5, 1 Southbank Boulevard,
Southbank, Melbourne, Victoria.
Our contact details are:
Ansvar Insurance Limited
Phone: 1300 650 540
Post: GPO Box 1655, Melbourne, Victoria 3001
Email: [email protected]
Website: www.ansvar.com.au
ABN 21 007 216 506 AFSL 237826
Complaints and disputes
If you are not satised with the service provided by Ansvar please
contact the employee with whom you have had contact to see if he
or she can resolve the problem.
If your complaint cannot be resolved you can request that the matter
be referred to the Secretary of the Ansvar Internal Dispute Resolution
(IDR) process at [email protected]. Alternatively, you can write
to The Secretary, Internal Dispute Resolution Committee, Ansvar
Insurance, GPO Box 1655, Melbourne, Victoria 3001.
We will attempt to resolve the matter in accordance with our IDR
procedures.
If our IDR process is unable to resolve your dispute and you wish
to take the matter further you can lodge a claim with the Australian
Financial Complaints Authority (AFCA). AFCA is an independent
service to deal with complaints from consumers and small business
about nancial services and products. If we are unable to resolve
your complaint, you may seek advice from AFCA.
Contact the Australian Financial Complaints Authority
Website: www.afca.org.au
Phone: 1800 931 678
Email: [email protected]
Post: GPO Box 3, Melbourne, Victoria 3001
How to fill out this proposal form
All questions must be answered in relation to the organisation to
be insured and all its subsidiaries and controlled entities (if any).
Please tick the box next to the correct answer and/or write the
information requested in the space provided.
If you require more space to answer any questions or to describe
any matter you need to disclose to us, please provide this
information on a separate signed sheet of paper or attach the
relevant document(s) to this proposal.
It is critical that you refer to the Product Disclosure Statement
for full terms and conditions of the policy.
Please ensure this form is signed and dated by an authorised person.
Office Use Only
Intermediary name Account number Policy number
Page 3
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
Proposal Form
Please select the Sections of cover you require:
Part A: Property and Income Protection
Property Protection Section Yes No
Breakdown of Mechanical and Electronic Equipment Section
Cover A – Breakdown of Mechanical Equipment Yes No
Cover B – Breakdown of Electronic Equipment Yes No
Money Section Yes No
Theft Section Yes No
Income Protection Section Yes No
Part B: General Liability
General Public and Products Liability Section Yes No
Part C: Tax Audit
Tax Audit Section Yes No
Policyholder details
This section must be completed.
Name of organisation to be insured (include any subsidiaries)
Trading Name (s) past and present (if applicable)
ABN / ACN / ARBN Date your organisation rst commenced operations
Postal Address State Postcode
Do you have a current stamp duty exemption for general insurance? Yes No
If yes, which State(s) or Territory does it apply for?
Exemption certicate date?
A copy of your exemption certicate must be provided with this proposal form, otherwise Stamp Duty will be applied to your premium.
Are you registered for GST? Yes No
If yes, what is your ITC percentage?
Authorised contact person Position Telephone
Mobile Email Website
Period of insurance
This section must be completed.
Required period of insurance
Commencement
date: Date:
Expiry date: Date:
Page 4
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
Information about your organisation
Organisational structure
This section must be completed.
How is your organisation structured?
Company limited by guarantee Cooperative / Mutual Incorporated association Partnership
Private company Privately held company Public company (ASX listed) Public company (not listed)
Unincorporated association Other (please specify)
The following questions must be completed if Part B: General Liability is required.
Is your organisation a subsidiary of another entity? Yes No
If yes, please provide the name of the ultimate holding organisation, its country of incorporation and its website:
Activities
This section must be completed.
Please provide a full description of the business activities of all entities to be insured by this policy:
Has there been any change in the nature of your business activities and those of your subsidiaries in the last 3 years? Yes No
If yes, please provide details:
Do you anticipate any major change in the nature of your business activities and those of your subsidiaries in the
next 12 months?
Yes No
If yes, please provide details:
Locations
This section must be completed.
Please advise the locations from which you operate:
Address Postcode State Owned by you? Occupied by you?
Yes No Yes No
Yes No Yes No
Page 5
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
Risk management
This section only needs to be completed if Part B: General Liability is required.
Are you required to be licensed, registered or accredited? Yes No
If yes, do you have such licence, registration or accreditation? Yes No
Expiry date
Is there any matter currently pending which may impact on your licence, registration or accreditation, or cause
them to be suspended or withdrawn? If yes, please provide details
Yes No
Do you follow a documented risk management system which includes regular analysis, evaluation and prevention
of risks associated with your business including the use of incident report procedures? Ansvar may request evidence of
your risk management policy.
Yes No
Is management actively involved in the risk management of your organisation? Yes No
Do you have an audit or compliance committee in place? Yes No
Do you have an OH&S or WorkSafe committee in place? Yes No
Do you ensure all Government regulations are closely abided with and have a dedicated person to implement and monitor? Yes No
Are all your premises, plant and machinery in good repair and are all statutory requirements complied with? Yes No
If no to any of the above, please provide full details:
If you engage any subcontractors / contractors / labour hire personnel to perform business-related activities on your behalf:
What is the estimated annual payment to subcontractors / contractors / labour hire personnel?
Do you ensure all subcontractors / contractors / labour hire personnel have their own Public Liability insurance? Yes No
People
This section only needs to be completed if Part B: General Liability is required.
Number of employees / other persons engaged in the organisation in Australia This year Last year
Directors / Partners / Supervisory / Management:
Full-time employees (administration only):
Full-time employees (some manual work):
Part-time / Casual employees:
Contract workers / temporary employees:
Financials
This section only needs to be completed if Part B: General Liability is required.
Please provide a copy of your latest 2 annual reports, nancial accounts, rules and procedures, codes of conduct or other documentation
which may assist us to gain a complete appreciation of the nature of your organisation.
If your organisation is commencing operations now, please provide a copy of your budgeted nancials.
Particulars Last Financial Year Previous Financial Year
Current assets
Current liabilities
Total assets
Total liabilities
Intangibles:
Total income/turnover (including grants, subsidies, fees):
Net prot (loss) after tax:
Page 6
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
Estimated total income/turnover (including grants, subsidies, fees, donations) for the next 12 months
Turnover % split per state
ACT % NSW % VIC % QLD % SA % WA % TAS% NT % Overseas %
For any overseas turnover please advise countries:
History
Previous Insurance
This section must be completed.
The questions relate to all Sections of cover being requested under this proposal for insurance.
Are you currently insured? If yes, name of previous insurer(s): Yes No
Expiry date:
Have you ever had any insurance declined or cancelled, application rejected, renewal refused, claim rejected, special
conditions or excess imposed by any insurer? If yes, please provide details:
Yes No
During the last ve years, have you claimed under a policy of insurance that this insurance is proposed to replace? If
yes, please provide details:
Yes No
Is there now any claim pending or are you aware of any circumstances that may give rise to a claim against you or
any other director or ocer of the entity applying for this insurance? If yes, please provide details:
Yes No
Insurer Date of incident Description of loss/circumstances Amount paid/outstanding
Organisation History
This section must be completed.
The following questions relate to all Sections of cover being requested under this proposal for insurance.
Has your organisation or any of its directors / ocers / executive managers / trustees:
a. ever been convicted of a criminal oence? Yes No
b. ever been declared bankrupt? Yes No
c. ever become insolvent or placed into liquidation or receivership? Yes No
Page 7
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
Only complete this section if Property and Income Protection is required.
Location information
Please advise the locations for which you require buildings and/or contents cover:
Location one Address State Postcode
Location two Address State Postcode
If you have more than two locations, please provide details on a separate page.
Location one Location two
Is the building:
Owned by you
Occupied by you
Describe the activities at the location:
What year was the building constructed?
When was the building last rewired?
Construction of exterior walls:
Timber
Brick Veneer
Reinforced Concrete
Reinforced Masonry
Unreinforced Masonry
Steel / Iron
Unknown
Are you aware of any asbestos at the location? Yes No Yes No
If yes, describe the type of material, quantity and your remedial plans:
What is the condition of the buildings?
Good
Fair
Poor
Number of storeys (including ground)
Does the building have a basement? Yes No Yes No
Fire Protection:
Fire Extinguishers
Hose Reels
Sprinkler System – single water supply
Sprinkler System – dual water supply
Security:
Back to base monitored alarm
Local alarm
Deadlocks and key locks to all external exits
Deadlocks only
Part A: Property and Income Protection
Page 8
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
Page 8
Policy Coverage
Property Protection Section
Only complete this section if Property Protection Section is required.
Location one Location two
Replacement Value Replacement Value
Declared values for insured property
Buildings including xtures and ttings:
General contents and property you are responsible for:
Stock:
Other specied contents (please attach a separate list of specied items):
Extra Costs of Reinstatement (costs to comply with Acts of Parliament or other regulatory bodies)
Limited to 20% of the building replacement value
Removal of Debris
Limited to the lesser of $500,000 and 20% of the total declared values or amount nominated
The following extensions have standard limits that apply, unless a higher amount is nominated by you and agreed by us. If higher limits are
required, please nominate required limits below.
Extension Standard Limit Location one Location two
Required limit Required limit
Collections, trophies, curios, works of art, pictures, antiques (at
your location)
$5,000 per item, set or
collection
Playing surfaces $50,000 per event
Damage to external xtures and ttings including landscaping $25,000 per event
Frozen or refrigerated goods $10,000 per event
Glass breakage:
Frames and signs $10,000 per event
Temporary Shuttering and Signwriting $10,000 per event
Contents $10,000 per event
Property in the open air $25,000 per event
Rewriting or reconstruction of records $50,000 per event
Works of art, pictures, curios and antiques (away from your
location)
$5,000 per item, set or
collection
$50,000 per event
Breakdown of Mechanical and Electronic Equipment Section
Cover A – Breakdown of Mechanical Equipment
Only complete this section if Breakdown of Mechanical Equipment Section is required.
If dierent limits are required at each location, please specify below. Otherwise the limits entered for Location one will apply to each location.
Extension Standard Limit Location one Location two
Required limit per item Required limit per item
Mechanical equipment $5,000 per item
Page 9
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
If you have any mechanical equipment with a replacement value exceeding $5,000, please list below:
Item Replacement Value Location one Location two
Yes No Yes No
Yes No Yes No
Yes No Yes No
Optional Extension Location one Location two
Do you require cover for deterioration of refrigerated goods? Yes No Yes No
Standard limit Required limit Required limit
$10,000 per event
Cover B – Breakdown of Electronic Equipment
Only complete this section if Breakdown of Electronic Equipment Section is required.
If dierent limits are required at each location, please specify below. Otherwise the limits entered for Location one will apply to each location.
Cover Standard Limit Location one Location two
Required limit per item Required limit per item
Electronic equipment $5,000 per item
If you have any electronic equipment with a replacement value exceeding $5,000, please list below:
Item Replacement Value Location one Location two
Yes No Yes No
Yes No Yes No
Yes No Yes No
Optional Extension Location one Location two
Do you require cover for data media material and records? Yes No Yes No
Standard limit Required limit Required limit
$5,000 per event
Do you require cover for increase in cost of working? Yes No Yes No
Standard limit Required limit Required limit
$5,000 per event
Indemnity period: 3 months 6 months 9 months 12 months
Money Section
Only complete this section if Money Section is required.
If dierent limits are required at each location please specify below, otherwise the limits entered for Location one will apply to each location.
Location one Location two
Limit required for Money:
The following standard limits apply, unless a higher amount is nominated by you and agreed by us. If higher limits are required, please nominate
required limits below.
Standard Limit Location one Location two
Required limit per item Required limit per item
Money in your buildings but not contained within a locked safe
outside business hours:
$5,000
Page 10
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
Theft Section
Only complete this section if Theft Section is required.
If dierent limits are required at each location please specify below, otherwise the limits entered for Location one will apply to each location.
Location one Location two
Limit required for Theft
The following standard limits apply, unless a higher amount is nominated by you and agreed by us. If higher limits are required, please nominate
required limits below.
Further Extension Standard Limit Location one Location two
Required limit Required limit
Musical instruments, other portable audio, video or sound
equipment, and sporting equipment
$1,000 per item
$5,000 per event
Income Protection Section
Only complete this section if Income Protection Section is required.
If dierent limits are required at each location please specify below, otherwise the limits entered for Location one will apply to each location.
Location one Location two
Gross income including all money paid or payable to you:
Indemnity period: 12 months 18 months 24 months Other
Optional Extensions Location one Location two
Required? Sum Insured Sum Insured
Additional increase in cost of working: Yes No
Additional severance pay: Yes No
Additional accounting and other professional costs (Claims preparation costs): Yes No
Fines and penalties: Yes No
Book debts: Yes No
Specied suppliers: Yes No
If Optional Extension Specied Suppliers is required, please specify the suppliers below:
Page 11
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
Only complete this section if Part B: General Liability is required.
Activities
Do you perform any activities outside Australia? Yes No
If yes, please advise type of activities and the countries where they are conducted.
Do you manufacture, import or export any Products? Yes No
If yes, please provide full details of all Products manufactured, imported or exported, including the countries, over the
last ten years:
Policy Coverage
General Public and Products Liability Section
Only complete this section if General Public and Products Liability Section is required.
Limit required: $5,000,000 $10,000,000 $20,000,000 $30,000,000 $40,000,000 $50,000,000
Standard Excess: Nil $1,000 $2,500 $5,000 Other
Note: an additional excess applies to claims for personal injury to subcontractors / contractors. This will be detailed within our terms.
Optional Extensions Required?
1. Occupational Health and Safety Breaches Yes No
2. Trauma Counselling Costs: Yes No
Part B: General Liability
Page 12
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
Only complete this section if Part C: Tax Audit is required.
Policy Coverage
Tax Audit Section
Only complete this section if Tax Audit Section is required.
Insuring Clause Required?
Tax Audit Yes No
Limit required: $20,000 $50,000 $100,000 $250,000 $500,000
Do you comply with requirements under Commonwealth, State or Territory legislation in relation to tax audits? Yes No
If no, please provide details:
Have you been subject to any investigation or tax audit by any Commonwealth, State or Territory department in
the last twelve months?
Yes No
If yes, please provide details:
Part C: Tax Audit
Page 13
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
Declaration
I/We:
a. declare the answers given and statements made are to the best of my/our knowledge true, correct and complete and that I/we have not
withheld any information likely to aect the acceptance of this application or the terms on which it is accepted;
b. declare that I/we have read and understood the Important Notices set out in the proposal and I/we are authorised to make this proposal;
c. acknowledge that the information contained in this proposal and any attachments will be the basis of the Commercial Property Owners
Insurance contract between the named organisation and Ansvar Insurance Limited and is subject to the terms, conditions and provisions
contained in the Commercial Property Owners Insurance Policy underwritten by Ansvar;
d. acknowledge and consent to the information supplied in this proposal to Ansvar being used for both the principal purpose of assessing
this application for insurance cover and the secondary purpose of disseminating to the business entity information, notices and details
regarding this insurance policy and services distributed or oered by Ansvar;
e. declare that I/we have made all due enquiries necessary in order to comply with the Duty of Disclosure;
f. acknowledge that no contract of insurance is in force until Ansvar has conrmed acceptance of the proposed insurance;
g. declare that I/we have read Ansvar’s Privacy Policy and consent to the collection, use and disclosure of personal information about the
Insured for the purposes shown in the Privacy Statement.
Please tick the box if you do not wish to receive any marketing material from us.
Signed Date
Name Position
Signed Date
Name Position
Attachments
Please attach to this proposal:
i. any documentation we have requested for the Sections of cover you require
ii. details of any other information which you think may aect your insurance or which we should be advised of (see “Your duty of
disclosure”); and
iii. any additional information which may assist us to gain a complete appreciation of the nature of your business.
Page 14
Ansvar Insurance Limited
Commercial Property Owners Insurance Proposal Form
CPOPROP V1.0 1216
Level 5, 1 Southbank Boulevard, Southbank VIC 3006
Ansvar Insurance Ltd. ABN 21 007 216 506 AFSL 237826
Member of the Ecclesiastical Insurance Group
CPOPROP V1.0 1216
1300 650 540 www.ansvar.com.au
