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Public Liability Form

General Information
*Required
 

Business Information

Please advise the following

 

Turnover Split per state/territory

Risk

If yes please complete import/export questions.

Imports

Exports

General History

After investigation are you or any principal, director or partner aware"

DECLARATION

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

a) declare that:

i. the answers and information given by me/us in this Application are true and correct in all respects;

ii. no information has been withheld that would affect an insurers decision to accept this Application;

iii. where answers in this online application have not been competed by myself, they have been checked by me/us and I/we agree they are correct and true;

iv. I/we have read and understood the financial Financial Services Guide and Privacy Statement;

v. if there was insufficient space to fully answer any questions, I/we have attached supplementary pages providing the additional information required.

b) authorise Wallace Risk Solutions Pty Ltd 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.