Proposal Form
Quotation Form
JLT – Insurance Partners
to the Crane Association
Insured:
Situation of Depot:
Postcode:
Years in Business:
Current Insurer:
Due Date:
Claims History (for the last 5 years):
Business Activities (Please also provide details of occupation, turnovers, staff numbers, individual crane operator experience
Item
Year/Make/Model/Serial
Tonne
Reg No.
Market Value
1
2
3
4
5
Note: Please attach a schedule if more space is required
Section 1 - Damage
Items to be Covered:
Wet Hire:
%
Dry Hired:
%
Damage Waiver:
If yes to dry hire, please attach a copy of clients hire conditions:
Use of Machines Underground (additional information required)
Section 2 – Hired-In Plant (Standard $50K extension for ongoing Hiring Charges in the event of claim)
Specified Cover.
Items to be covered:
Blanket Cover. Please fill in the following:
Types of items to be hired in ie. Excavators:
Max sum insured all items
$
Any one item
$
Hiring charges paid by client (annual):
Section 3 – Additional Benefits for Sections 1 and 2 (1-20 apply automatically)
1
Damage to Lifted Goods:
Sum Insured $250K Increase to Limited (500K/1M)
$
2
Multiple Crane Operation
3
Expediting Costs:
Sum Insured $25K or 25% of Indemnity, lesser applies
4
Recovery Costs – No Damage:
Sum Insured: $75K
5
Recovery Costs – Damage:
Sum Insured: $250K
6
Employees Property Damage
Sum Insured: $5K
7
Indemnity to Hirer – Wet Hire
8
Appreciation in Value
9
Extra Costs of Reinstatement
Sum Insured: $50K
10
Additions/Deletions of Machines:
Sum Insured $500K – Notify within 60 days notification
11
Agreed Value (written valuation required)
Optional:
Items:
12
Market Value Plus
Optional:
Items:
13
Owners Protection
Optional:
(applies to wet hire activities)
14
Owners Protection Plus
Optional:
(applies to wet and dry hire activities)
15
Hired-Out Plant (Damage Waivers)
Optional:
Items:
$
Section 4 – Financial Protection (Indemnity Period 12 months)
Loss of Revenue and
Increased cost of working
Items:
Sum Insured per item: (20, 50, 100K)
$
Period:
Increased cost of working
Items:
Sum Insured per item: (20, 50, 100K)
$
Period:
Lease Payments Protection
Items:
Monthly Repayment Figure:
$
Period:
Lease Value Protection
Items:
Section 5 - Breakdown
Items:
Section 6 – Road Risk
(Third Party Property Damage) 10M
Section 7 - Liability
Broadform Liability (Public/Products Liability) Limit of Liability(5/10/20/30M)
$
Statutory Liability - Limit of Liability - 1M automatic (advise if higher limit required)
$
Employers Liability – Limit of Liability - 1M automatic (advise if higher limit required)
$
Subcontractors/Contractors:
Annual Payments:
Use of machines in connection with Rail (add info required)
Labor Hire: Annual Payments:
Importing / Manufacturing (add info required)
Privacy Act Declaration
Pursuant to the Privacy Act 1993 the following is bought to your attention:
1. You have provided commercial and personal information about you and you organisation;
2. The intended recipients of the information are your Insurers or prospective Insurers and the information has been collected to enable your
Insurers or prospective Insurers to evaluate your insurances;
3. The information is collected and held by Jardine Lloyd Thompson Limited (JLT) and/or your Insurers and/or prospective Insurers.
4. JLT are hereby authorised to release this information to other parties who may be required to assist us or the insurers, these third parties may
only use your personal information for the purposes provided to them (or if required by law).
5. The collection of this information is required pursuant to the common duty to disclose all material facts relevant to you insurances. You have
rights to access, and to correct, this information subject to the provisions of the Privacy Act 1993.
Duty of Disclosure
Before entering into a contract of general insurance with an insurer, you have a duty to disclose to the insurer all matters you are aware of, or could
reasonably be expected to be aware of, that are relevant to the decision whether to accept the risk and the terms that will be applied.
Failure in your Duty of Disclosure, or breach of any Policy condition or Warranty, could result in an otherwise legitimate claim being declined, a reduction
in a claim settlement or your nondisclosure is fraudulent your Policies could be declared null and void from it’s inception.
The same duty of disclosure also applies in the event that you renew, extend, vary or reinstate your contract of insurance.
Declaration
I/We declare that the statement and particulars provided in this Proposal are true and correct in every detail, and that no information has been withheld
that might influence acceptance of the insurance and that no material facts have been misrepresented, suppressed or omitted.
I/we agree and understand that the Proposal, signed by or caused to be signed by me/us shall be the basis of and form part of the Contract between
me/us and the Insurers.
Name:
Title/Position :
Signature:
Date:
JLT – Insurance Partners to the Crane Association
Philip Clauzel
T +64 (0) 9 300 6666
M +64 (0) 21 868 050
[email protected]
Hayley O’Connor
T +64 (0) 300 6660
M +64 (0) 21 167 8509
[email protected]
Jardine Lloyd Thompson, Level 5, 45 Queen Street, PO Box 6743,
Auckland 1141, New Zealand P: 64 (9) 379 5376 F: 64 (9) 309 2942
E: [email protected]
www.jlt.co.nz