Commercial Products Fact Find
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Ever had an insurance policy cancelled, declined or terms imposed? | Yes |
---|---|
Ever been declared bankrupt? | Yes |
Ever been involved in a company or business which became insolvent or subject to any form of insolvency administration (e.g. liquidation or receivership)? | Yes |
Been convicted of any criminal offence within the past 5 years (other than minor traffic convictions)? | Yes |
Been liable for any civil offence or pecuniary penalty (exceeding $5,000)? | Yes |
Any other matters you should disclose? | Yes |
Do you want to provide any important information for the insurer? | Yes |
Full Time | Part TIme | |
---|---|---|
Principals, par tners and direc tors | 4 | 4 |
Full Time | Part TIme | |
Qualified profe ssionals | 4 | 4 |
Other technical staff | 76 | |
Administrative and clerical st aff | 37 | 6 |
Contractors | 4 | |
Volunteers | 6 | |
Other | 5 |
Last financ ial year (a ctual) $ | Current fin ancial year (projected ) $ | Next financ ial year (e stimated) $ | |
---|---|---|---|
New Zealand | 3345 | 5642 | 5678 |
Australia | 54 | ||
Pacific Isl ands | |||
Asia | 67 | 34567 | |
UK & Europe | 987 | ||
Last financ ial year (a ctual) $ | Current fin ancial year (projected ) $ | Next financ ial year (e stimated) $ | |
USA & Canad a |
Name of potential claimant | Brief description of matter | Estimate of potential liability($) | Has claim been previously notified? If ‘Yes’, when?? | |
---|---|---|---|---|
1 | er | t | e | |
2 | fr | tf | ed | |
3 | t | ge | ||
4 |
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These templates are suggested forms only. If you're using a form as a contract, or to gather personal (or personal health) info, or for some other purpose with legal implications, we recommend that you do your homework to ensure you are complying with applicable laws and that you consult an attorney before relying on any particular form.