Locksmith Application Form

Contact Name:*
Email:*
Phone Number
Business Established

Legal Entity:
Trading Name:*
ABN
Website:
Mailing Address
Number:
Street:
Suburb:
State:
Postcode:

Tick the relevant Activities
ESTIMATED TURNOVER FOR THE NEXT 12 Months: *
ACTUAL TURNOVER LAST 12 MONTHS: *
Number of Proprietors / Partners / Principals giving advice:
NUMBER OF WORKERS:
(e.g. Directors / Employees / Labour Only Sub Contractors / Work Experience)
Confirm Experience of Proprietors/Partners/Directors/Principals exceeds 1 year?
Turnover Split By State
NSW *
VIC
QLD
WA
SA
NT
ACT
TAS
TOTAL

Note, a small business under the changes relating to the NSW Stamp Duty exemption defines that a business is a small business for an income year (the current year) if:

You carry on a business in the current year; and
One or both of the following applies:

  1. You carried on a business in the income year (the previous year) before the current year and the aggregated turnover for the previous year was less than $2m;
  2. The aggregated turnover for the current year is likely to be less than $2m.

For more information, visit: https://www.revenue.nsw.gov.au/taxes-duties-levies-royalties/insurance-duty/exemptions


Public Liability: $20,000,000
Professional Indemnity: $1,000,000
Loss of Keys $250,000
Statutory Liability $500,000
Public Liability Only

Have You or any director or partner involved with the Business or any other business have in the past 5 years:

Ever been declared bankrupt or insolvent:
Ever been convicted of or charged (but not yet tried) or been given an Official Police Caution in respect of any criminal offence other than a motoring offence:
Ever had any previous insurer decline a proposal, refuse to renew a policy or impose special terms or conditions:
Ever been convicted of any offence relating to the Health and safety of your employees or members of the public in connection with your business:
If Yes, please provide full details

In connection with The Business or any other business in which You or any director or partner are, or have been involved, and in respect of the cover(s) now granted:

There have been losses/claims made for the risks proposed exceeding $1,000 in the last 5 years: *
There have been losses/claims made for any tools of trade in the last 5 years whether insured or not
If Yes, please provide full details

This declaration must be completed and signed by or on behalf of the party applying for insurance.
The proposer/I/We

  1. declare that:
    1. the answers and information given by me/us in this Application are true and correct in all respects;
    2. no information has been withheld that would affect an insurers decision to accept this Application;
    3. where answers in this online application have not been completed by myself, they have been checked by me/us and I/we agree they are correct and true;
    4. I/we have read and understood the Financial Services Guide and Privacy Statement;
    5. if there was insufficient space to fully answer any questions, I/we have attached supplementary pages providing the additional information required.

  2. authorise Wallace Risk Solutions to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to these insurance covers, and any other insurances held by me/us and claims under those insurances.
Name