Name* First Last Owner Builder Name*Phone Number*Email Address*Job AddressStreet Name & Number*Suburb*Post Code*Job Description*Select oneNew DwellingAllteration / Addition to Existing DwellingRenovationDuplexUnitsTownhouses / VillasCompletion of Existing ProjectProject Value*Public Liability* $20 000 000 $10 000 000 Is there an Existing Structure?* Yes No Do you want us to quote for the Existing Structure?* Yes No Existing structure replacement value*Will Excavation Exceed 2m?* Yes No Construction* Brick Other Other Construction:*Construction of a Pool* Yes No Do you hold an owner builder permit for this project? Yes No Please provide the owner builder permit number if availableHas there been any previous claims at this site or for any previous owner builder projects? Yes No To the best of your knowledge, have your or any person for whom the insurance will cover* Has an insurer decline a claim, cancel insurance or impose special terms on an insurance policy Been charged with, pleaded guilty or convicted of a criminal offence Been in any way associated with or been a member of a crime or outlaw motorcycle gang Been declared bankrupt Been a defendant in a civil law case Been involved a company that has gone into any form or liquidation, administration or receivership Yes No Has work commenced?* Yes No Approximate Start Date* DD slash MM slash YYYY Will there be any Retaining walls greater than 15 meters in length and/or 1 meter in height?* Yes No If yes please provide details in the additional information section.Will there be work involving piling, shoring or underpinning?*If yes please provide details in the additional information section. Yes No Would you like voluntary workers cover to cover yourself and friends or family who assist on site for no income?* Yes No What injury benefit would you like?* $300 per week up to 26 weeks $500 per week up to 26 weeks Preferred Method of Contact* Email Phone Any Additional InformationCAPTCHANameThis field is for validation purposes and should be left unchanged. Δ
