Public Liability Renewal Declaration

Your liability insurance lapses soon. Please complete and submit this form immediately, so that we can obtain renewal terms. This renewal declaration will form a key part of your ongoing contract(s) of insurance and it is important that all material facts continue to be fully, frankly and accurately disclosed.

Insured name:

Enter the name of the entity that is insured (eg. the business name)

E-mail

example@example.com

Policy no.

Expiry date:

Select the activities that represent at least 90% of what you do. Add the approximate percentage each of them is of your total business. If something is not on the list select Other and describe it in the box below.*

If "Other" is selected, please describe the activity here:

Approximately, what proportion of your residential and light commercial building work is:*

	Approximate Percentage
New Home Construction
Residential Alterations & Renovations
Light Commercial

If "Builder (Heavy Commercial & Industrial)" is selected, please tell us the types of buildings you work in or on (eg. power stations, factories, mills, warehouses, building more than 3 storeys):

Does your business include property development?*

YesNo

You would be considered a property developer if you benefit (ie. make a profit) from buying and improving land, constructing new buildings, renovating existing ones and subdividing property to increase its value. If you only perform the work and don’t benefit from an increase in the value of the asset (eg. when it is sold) then you are not considered a property developer.

Approximately, what proportion of your turnover is from property development?

Do you import any building products directly from overseas or have any operations outside of New Zealand?*

YesNo

Please provide more information on what you are doing:

Select these options only if you take on any contracts that are just for:

Project management means where you charge a fee for managing a contract that is between two other parties. If you hold the actual build contract, even if you subcontract all the work, you are still considered the building contractor not a project manager in terms of the insurable risk.

Select these options only if any of your contracts may involve:

construction of buildings greater than 3 storeysprecast panel manufacturingstructural steel erection (other than for individual residential builds under $2.5m)use of explosivescivil construction - including road, bridge, tunnel, dam constructionworking in or with foam panel buildings or structures larger than 200sqmearthquake strengtheninghouse movingtunneling & working underground

No. of employees (year ahead):*

Include deemed employees, principals & working directors

Estimated turnover (year ahead):*

This means your total sales through the business

Actual turnover (last year):

This means your total sales through the business

Estimated turnover (year ahead):*

This means your total sales through the business

Actual turnover (last year):

This means your total sales through the business

Has any insured person, director or shareholder been declared bankrupt, insolvent or is currently unable to meet their debts?

YesNo

If "Yes", please advise details:

Please give a full description of your main business activities (these should represent around 90% of the work you do):*

3. Describe any other minor activities you may do but that are not part of your general day to day business (ie. not described above):

Has your business changed in any way during the past year, or do you anticipate any changes in the forthcoming period?*

YesNo

If "Yes", please advise details:

In the last three years have there been any claims made against you, or are you aware, after enquiry, of any circumstances which could give rise to a claim under your policy?*

YesNo

If "Yes", please advise details:

Have you ever had liability insurance declined, cancelled or been refused by an insurer?*

YesNo

If "Yes", please advise details:

File Upload

Important

(a) Any material changes to the business during the Period of Insurance must be advised immediately.
(b) This form must be completed by a person authorised to do so on behalf of the Policyholder.
(c) If this application is for Directors and Officers, Trustees or Associations Liability then you must attach a copy of your latest consolidated financial report.

Declarations

(a) all information provided, in this declaration or attachments, is true and complete in every respect and that no Material Facts remain undisclosed;
(b) if this risk is accepted, such information will be incorporated into and form the basis of the contract of insurance;
(c) I/We understand that the Proposed Insurer requires this information in order to evaluate this proposal and that the Privacy Act 1993 entitles me/us to have access to, and request the correction of, any information retained;
(d) the Proposed Insurer is authorised to disclose information to its advisers, reinsurers, other insurers and parties with a financial interest in the subject matter of this declaration;
(e) the Proposed Insurer is authorised to check details against the Insurance Claims Register and to place information on the Insurance Claims Register which other insurers can access;
(f ) the Proposed Insurer is authorised to obtain from other parties any information which may be relevant to the acceptance of this risk;
(g) the signing of this declaration does not bind either party to complete the contract and that no cover will be in force until confirmed by the Proposed Insurer;
(h) I have the authority to represent the Insured.

Agree

On behalf of all proposed Insureds I/We declare and agree that:*

(a) all information provided, in this declaration or attachments, is true and complete in every respect and that no Material Facts remain undisclosed;(b) if this risk is accepted, such information will be incorporated into and form the basis of the contract of insurance;(c) I/We understand that the Proposed Insurer requires this information in order to evaluate this proposal and that the Privacy Act 1993 entitles me/us to have access to, and request the correction of, any information retained;(d) the Proposed Insurer is authorised to disclose information to its advisers, reinsurers, other insurers and parties with a financial interest in the subject matter of this declaration;(e) the Proposed Insurer is authorised to check details against the Insurance Claims Register and to place information on the Insurance Claims Register which other insurers can access;(f ) the Proposed Insurer is authorised to obtain from other parties any information which may be relevant to the acceptance of this risk;(g) the signing of this declaration does not bind either party to complete the contract and that no cover will be in force until confirmed by the Proposed Insurer;(h) I have the authority to represent the Insured.

Your name:*

First NameLast Name

Date of declaration:*

DayMonthYear

YesNo

Would you like a quote for any of these additional liability policies that you may not have now:*

	Yes	No	I have It
Statutory liability: More
Employers liability: More
Full professional indemnity: More
LBP professional indemnity: More
Directors & officers liability: More
Employee disputes liability: More
Crime/Fidelity: More
Legal prosecution defense costs: More
Cyber: More

Builtin provides the complete range of commercial and domestic insurance. If you do not have all your policies with Builtin would you like us to give you a quote for your other insurances when they're next due for renewal?

YesNo

Renewal month for your other cover:

Would you like a quote for any of these additional liability covers:

Professional indemnity MoreDirectors & officers liability MoreEmployee disputes MoreCrime/Fidelity MoreLegal prosecution defense costs MoreCyber More

Virtual crime is now more common than physical crime. Experts recommend basic cybercrime insurance to all small businesses. Would you like to add this cover for just $285 per year? Read more

Currency

Select the activities that represent at least 90% of what you do. Add the approximate percentage each of them is of your total business. If something is not on the list select Other and describe it in the box below*

Annual Turnvover for ActiveCampaign

Number of Employees for ActiveCampaign

Policy Type

Liability Insurance Renewal Declaration