Swimming Pool Safety Inspection

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Title blue : 
Swimming Pool Safety Inspection
1. Details of The Proposer
if applicable
2. Business Activities
Files must be less than 5 MB.
Allowed file types: gif jpg png txt rtf html pdf doc docx odt.
3. General Information

If YES, please state:

4. Income Details (relating to swimming pool inspection/certification)
5. Certifier Information
CLAIMS HISTORY

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

  • of anyone having been charged with or convicted of any criminal offence (excluding traffic offences)? *
  • of any insurance being declined or cancelled, application / proposal rejected, renewal refused, claim rejected, or special conditions or excess imposed by any insurer? *
  • ever, either alone or jointly with others been declared bankrupt or subject to any form of insolvency administration (eg. liquidation or receivership)?

This declaration must be completed and signed (electronically) 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 completed 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 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. I acknowledge that, if a contract of insurance is entered into, this Proposal and any accompanying documents will form the basis of the contract.

 

To be signed by the insured for whom this insurance is intended for