Concrete Pumping Proposal Form

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This questionnaire should be completed in conjunction with the ISP Proposal Form. When completed, please sign this questionnaire where indicated, ensuring that prior to signing you have read and understand Your Duty of Disclosure and our Privacy statement.

Section A: General Information

Date

Years in Business

Policy No.

Insured Name

Insured Email*

Suburb

Postcode

Section B: Machines to be insured

The age of the pumping unit must be supplied

Truck

Truck details

Year / age

Description of units (make/model)

Rego

Sum Insured

Add more

Pump

Pump Details

Year / age

Description of units (make/model)

Rego

Sum Insured

Add more

Section C: Maintenance And Accreditation

Who undertakes maintenance / servicing of concrete pumping machines?

External Service Providers.

Yes

In House by Your Own Employees.

Yes

How often does maintenance/servicing take place?

Are all your concrete pumping machines certified in accordance with Australia Standard AS2550 and/or AS2550.15?. If no, provide reasons why in space provided

Yes

Reasons

Section D: Claims and/or circumstances

Who undertakes maintenance / servicing of concrete pumping machines?

File

Drop files here or

Max. file size: 100 MB.

Claims and/or circumstances list

Year

Claim Details

Incurred

Your duty of disclosure

Before you enter into an insurance contract, you have a duty to tell us anything that you know, or could reasonably be expected to know, may affect our decision to insure you and on what terms. You have this duty until we agree to insure you. You have the same duty before you renew, extend, vary or reinstate an insurance contract.

You do not need to tell us anything that:

Reduces the risk we insure you for; or
Is common knowledge; or
We know or should know as an insurer; or
We waive your duty to tell us about.

If you do not tell us something If you do not tell us anything you are required to, we may cancel your contract or reduce the amount we will pay you if you make a claim, or both.

If your failure to tell us is fraudulent, we may refuse to pay a claim and treat the contract as if it never existed.

QBE Privacy

We will collect personal information when you deal with us, our agents, other companies in the QBE group or suppliers acting on our behalf. We use your personal information so we can do business with you, which includes issuing and administering our products and services and processing claims. Sometimes we might send your personal information overseas. The locations we send it to can vary but include the Philippines, India, Ireland, the UK, the US, China and countries within the European Union.

Our Privacy Policy describes in detail where and from whom we collect personal information, as well as where we store it and the full list of ways we could use it. To get a free copy of it please visit qbe.com.au/privacy or contact QBE Customer Care.

It’s up to you to decide whether to give us your personal information, but without it we might not be able to do business with you, including not paying your claim.

UAA Privacy

UAA is committed to protecting the privacy of personal information in accordance with the Privacy Act 1988 (Cth). UAA’s privacy principles, set out at www.uaa.com.au, explain what personal information is collected from the Insured, why it is collected, how it will be used and to whom it can be disclosed

Declaration

Please remember we will treat a statement or claim or an act or omission by any one of the applicants as a statement or claim or an act or omission by all of the applicants.

I/ We have received a copy of the Policy wording QM2003
I/We declare that all answers and statements made in the application are true, correct and complete in every respect.

Signature

Signature of applicant

Add more

Concrete Pumping Proposal Form

This questionnaire should be completed in conjunction with the ISP Proposal Form. When completed, please sign this questionnaire where indicated, ensuring that prior to signing you have read and understand Your Duty of Disclosure and our Privacy statement.

Section A: General Information

Section B: Machines to be insured

The age of the pumping unit must be supplied

Truck

Pump

Section C: Maintenance And Accreditation

Who undertakes maintenance / servicing of concrete pumping machines?

Section D: Claims and/or circumstances

Who undertakes maintenance / servicing of concrete pumping machines?

Your duty of disclosure

QBE Privacy

UAA Privacy

Declaration

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure

If Existing Business

Insured Details

Director/ Owner

Policy

Duty Of Disclosure