IMPORTANT NOTCIES

THE ISSUERThis product is issued by:Edge Underwriting Pty Ltd (Edge) | ABN 50 150 700 468 | AFS licence No. 4076821/188 Adelaide Tce East Perth WA 6004under authority from certain underwriters at Lloyd's ("the Insurer"), who underwrite the policy.

PRIVACYEdge is committed to the protection of your privacy and is bound by the National Privacy Principles for the handling of your information. Edge’s Privacy Policy can be viewed online by visiting our website (edgeunderwriting.com.au).

YOUR DUTY OF DISCLOSUREUnder the Insurance Contracts Act 1984 (the Act), you have a Duty of Disclosure. You are required before you enter into, renew, vary, extend or reinstate your Policy, to tell us everything you know and that a reasonable person in the circumstances could be expected to know, is a matter that is relevant to our decision whether to insure you, and anyone else to be insured under this Policy, and if so, on what terms.

You do not have to tell us about any matter that diminishes the risk that is of common knowledge that we know or should know in the ordinary course of our business as an insurer, or which we indicate we do not want to know.

If you do not tell usIf you do not comply with your Duty of Disclosure we may reduce or refuse to pay a claim or cancel your Policy. If your non-disclosure is fraudulent we may treat this Policy as never having worked.

PLEASE ANSWER ALL QUESTIONSPlease answer all questions fully and ensure all information requested is provided. If there is insufficient room for you to fully answer any question, please attach a separate page.

General LiabilityInsurance Application Form

1/188 Adelaide Tce East Perth WA 6004

AUS (08) 9420 7900INT +61 8 9420 7900WWW edgeunderwriting.com.au

BROKERBroking House Broker Contact Details Ph. email: Date Quote Required by Holding or Attacking?

THE INSUREDFull Name(s) of Insured

Website: http://Fully describe the main activities

Head Office Address:

Address(es) of all other locations where premises are owned or leased by you:

Number of Years in this Business

FINANCIALSPeriod Turnover Wage roll No. of EmployeesActual (last 12 mths) $ $ Estimated (next 12 mths) $ $ Provide the approximate split of your activities (as a percentage of turnover) in the following locations:

ACT NSW NT SA TAS VIC WA QLD Overseas

% % % % % % % % %

PREVIOUS INSURANCECurrent Policy Expiry Date Current Insurer Current Premium $ Current Deductibles (Excess) General Claims $ W2W $

THIS INSURANCEPeriod of Insurance From 4:00pm To 4:00pm Limits of LiabilityPublic Liability $ Any one Occurrence

Products Liability $ Any one period of insurance

Sub-LimitsCare Custody & Control $100,000 Any one period of insurance

$ Any one period of insurance

$ Any one period of insurance

Required Deductibles (Excess) General Claims $ W2W $

HIGHER HAZARD ACTIVITIES

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Please tick the appropriate box if your business activities are at, on, or involve: Airports / Bridges / Canals / Dams / Railway or Rail Track infrastructure / Shipyards / Tunnels Yes ☐ No ☐ Asbestos Removal / Blasting / Demolition Yes ☐ No ☐ Chemical refineries / Mines or Quarries / Oil refineries / Oil refineries Yes ☐ No ☐ Critical parts manufacturing for marine, automotive or aviation industries Yes ☐ No ☐ Excavation / Underpinning / Shoring Up / Piling / Working at heights Yes ☐ No ☐ Tunnelling / Vertical or Horizontal drilling / Hydraulic fracturing (hydrofracking) Yes ☐ No ☐ Hot works (eg. Cutting / Welding / Grinding) Yes ☐ No ☐ Power generation or distribution Yes ☐ No ☐ Exports to, or manual work in, USA or Canada Yes ☐ No ☐ Advice, design, consultancy, specification, formulae or supervision for a fee Yes ☐ No ☐If Yes, please provide full details

CONTRACTORS & LABOUR HIRE Do you engage contractors and or subcontractors in your business? Yes ☐ No ☐If Yes: do you ensure that contractors and or subcontractors have their own liability and where

necessary Workers Compensation insurance? Yes ☐ No ☐ Estimate the amount to be paid to contractors and or subcontractors in the next 12

months: $

Describe their main activities:

Do you engage labour hire personnel in your business? Yes ☐ No ☐If Yes: Estimate the amount to be paid to labour hire personnel in the next 12 months: $ Describe their main activities:

PRODUCTS EXPORTED / IMPORTEDDo you export or import any products to or from overseas? Yes ☐ No ☐If Yes:Import or Export? List Products List Counties Exported To / Imported From Advise Turnover $ $ $ $ $ I have attached a copy of all current Product Certification Certificates for the Products Listed above Yes ☐ No ☐Please note that we are unable to bind cover if Certificates are not provided

HIRE (OUTWARDS) OF STAFF OR EQIPMENT Do you, or do you intent to, hire out any staff Yes ☐ No ☐If Yes:

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Advise activities undertaken Advise Turnover $ Do you, or do you intent to, hire out any equipment Yes ☐ No ☐If Yes:Advise type(s) of equipment Advise Turnover $ Advise split between wet and dry hire % dry % wet

LOSS HISTORYYear No of claims Amount Paid Outstanding Estimate Total Incurred

Expiring Year $ $ $Previous Year $ $ $Previous Year $ $ $Previous Year $ $ $Previous Year $ $ $

Have you ever suffered any uninsured liability losses or had any liability claims declined? Yes ☐ No ☐If Yes please provide full details:

DECLARATION

1. I/We declare that my/our attention has been drawn to the Important Notice at the beginning of this Application form and further I/We I have read these notices carefully and acknowledge my understanding of their content by my/our signature/s below.

2. I/We declare that all answers and statements made in this Application are true, correct and complete in every respect;

3. I/We declare that where any part(s) of the Application has been completed by others, I/We have checked their answers and confirm they are true, correct and complete in every respect;

4. I/We give permission for Edge Underwriting or the Insurer to collect or disclose any personal information relating to this insurance to/from any other insurers or insurance reference service.

5. I/We declare that should any information given by me/us alter between the date of this Application form and the inception date of the insurance to which this Application relates, I/We shall give immediately notice thereof.

6. I/We declare that the undersigned is authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this Application form and I/We complete this Application form on their behalf.

Named Signature Title Date

Named Signature Title Date

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