af172 (v1) contractor company insurance assessment form

8/12/2019 AF172 (v1) Contractor Company Insurance Assessment Form

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AF 172 (v1) RFC No. JABE -8ERVJ2 Page 1 of 3

CONTRACTOR COMPANY DETAILSThe following information is to be supplied ANNUALLY by any contractor who is engaged to performwork on a Hellmann site or for and on behalf of Hellmann. For any work or part of the work that will be

subcontracted out, full details of the subcontractor must be supplied separately.

Vendor Code (If known. This is assigned by Hellmann)

Full Name of Company ALLALONG TRUCKING AGENTS PTY LTD

Registered Business Address POST BOX 367

Suburb REVESBY NORTH

State NSW Post Code 2212

ABN Number 68 001 217 009 ACN Number 001 217 009

Name of Director/s, Individuals JOHN CANT , RAY CANT

Business Entity Incorporated Company Partnership

Individual or Sole Trader

Business Trading Name ALLALONG TRANSPORT

Business activities TRANSPORTING FREIGHT INTERSTATE

DECLARATIONDo you perform this type of work for anybody other than

Hellmann?

YES NO

If yes, approximately what percentage of your work is performedfor Hellmann? 5 %

Will you be engaging any subcontractors to perform work forHellmann?

YES NO

At the time of orientation to a Hellmann site do you agree tosupply, upon request, documentation including risk assessments,training records, fatigue management records, equipment servicerecords or material safety data sheets, or any otherdocumentation which will ensure the safety of people on

Hellmann sites.

YES NO

Company Contact Name JOHN CANT, GENERAL MANAGER

Contact Numbers Office 02 9792 8787 Mobile

Email Address [email protected]

Signature .. Date ..


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CONTRACTOR INSURANCE DETAILS

PUBLIC LIABILITYDo you hold a Public Liability Insurance Policy in respect ofthe work you will be performing for Hellmann?

YES NO

If yes please provide the following details:

Name of Insurer ZURICH AUSTRALIAN INSURANCE LTD

Policy Number 17086723XGLG Due Date 20/08/2011 (Use format dd/mm/yyyy)

Amount of the Cover $ 10,00,000.00

Limit of Indemnity $ 5,00,000.00

Amount of any Excess $ 500

Does this policy indemnify principals? YES NO

Certificate of Currencyattached?

Can be obtained from your insurer orbroker. A Tax Invoice is not aCertificate of Currency

YES NO

WORKERS COMPENSATIONDo you employ workers, or do you intend to employ workersfor this contract?

YES NO

If yes, your company is required by law to have adequate Workers Compensation cover for all employees.

Do you hold a Workers Compensation Policy covering allpotential liabilities under the relevant state legislation?

YES NO

If yes please provide the following details:

Which state/territory do you work for Hellmann. Please tick one or more boxes

NSW QLD VIC ACT WA SA TAS NTPLEASE NOTE THAT WHERE A COMPANY WILL BE CARRYING OUT WORK FOR HELLMANN IN MORETHAN ONE STATE OR TERRITORY, PROOF OF WORKERS COMPENSATION INSURANCE FOR EACHSTATE OR TERRITORY WILL BE REQUIRED.

Name of Insurer EMPLOYERS MUTUAL & ALLIANZ

Policy Number 21222016 & LWL0009974 Due Date 30/06/2011 (Use format dd/mm/yyyy)

Limit of Indemnity $ $10.00MILLION



YES NO


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PERSONAL INJURY / INCOME PROTECTIONDo you (the contractor) have personal injury / incomeprotection insurance?

YES NO

This is suitable for Individuals, individual sole traders and partnerships, but this is not compulsory.

Name of Insurer

Policy Number Due Date (Use format dd/mm/yyyy)

Amount of the Cover $

Amount of any Excess $


Can be obtained from your insurer orbroker. A Tax Invoice is not a Certificateof Currency

YES NO

MOTOR VEHICLE

For all vehicles that will be used to perform the work on behalf of HellmannAre all vehicles that will be used, insured against Third PartyProperty Damage

YES NO

If yes please provide the following details:Name of Insurer

Policy Number 332983346vft Due Date 20/08/2011 (Use format dd/mm/yyyy)

Limit of Indemnity $30.00 MILLION

Amount of any Excess $ VARYING

Are there any specialconditions?

YES NO I f so, please speci fy:(Attach separate page if required)



YES NO

PLANT & EQUIPMENTAre all plant & equipment that will be used inthe performance of the work, insured againstThird Party Property Damage

YES NO

If yes please provide the following details:Name of Insurer ZURICH AUSTRALIAN INSURANCE LIMITED

Policy Number 332983346VFT Due Date 20/08/2011 (Use format dd/mm/yyyy)

Limit of Indemnity $30.00 MILLION

Amount of any Excess $ VARIOUS

Are there any specialconditions?

YES NO If so, please specif y:(Attach separate page if required)

Certificate of Currency

attached?

Can be obtained from your insurer or

broker. A Tax Invoice is not a Certificateof Currency

YES NO

af172 (v1) contractor company insurance assessment form

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