Commercial Products Fact Find
Commercial Products Fact Find
Duty of Disclosure
Have you or any partner(s) or director(s) of the business:
| 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 |
Claims
Any claims in the last 3 years?
Yes
Number of Claims?
6
Policy Type
Liability
Date of Loss
Tuesday, October 15, 2024
What was the total cost of the claim?
456789
Description
des
Period of Insurance Required
Tuesday, October 8, 2024
Renewal Date
Monday, October 7, 2024
Liabilities
Number of Employees?
45
Business Occupation
Name
Actual Turnover in the Last Financial Year
234
Estimated Turnover Next Financial Year
345
Add Activity?
Yes
Business Occupation
4567
Actual Turnover in the Last Financial Year
23456
Estimated Turnover Next Financial Year
234567
Add Activity?
Yes
Business Occupation
wadfg
Actual Turnover in the Last Financial Year
234
Estimated Turnover Next Financial Year
345
General Liability
Number of Locations
4
Territorial Limits
New Zealand
Hot Work
Percentage of turn
over from this wor
k?
Additional Hot Works Activity?
Yes
What hot work do you do?
Gas or Disc Cutting
Where do you undertake the hot work?
Own Premises
Percentage of turnover from this work?
345
What hot work do you do?
Use of Heat Guns
Where do you undertake the hot work?
Third Party Premises
Percentage of turnover from this work?
34
Do you use, store, handle, manufacture or transport any acids, chemicals, gases, inflammables, explosive, toxic or hazardous substances or materials?
Yes
Material Details?
Bulk liquids (hazardous and/or polluting)
Bulk liquids (non-hazardous)
Chemicals
Dangerous goods including liquid or gas fuels
Please provide more details
etdryfugi
Are hazardous goods used, stored or transported in accordance with the applicable laws?
Yes
Product Details
Have you withdrawn or recalled any products?
Yes
Is your business now or in the past been involved in the manufacture, distribution or sale of the following goods?
Aircraft or Aircraft Component Parts
Ethical Drugs / Pharmaceutical
Fertilisers / Pesticides / Fungicides
In relation to products, do you carry out work overseas or export any products you manufacture, sell, handle, supply or distribute?
Yes
Product/Activity #
1 Description
Type of Activity
Manufacture, Distribute & Export
Country of Overseas Work or Destination for Exported Goods
South Pacific
Total Turnover
5678
Coverages
Limit of Indemnity
$10,000,000
Specify General Indemnity Limit ($)
53465768798076756
Property Being Worked On/Defective Workmanship
Yes
Statutory Liability
Retroactive Type
Date
Retroactive Date
Monday, October 7, 2024
Limit of Indemnity
$1,000,000
Employers Liability
Retroactive Type
Unlimited
Retroactive Date
Tuesday, October 8, 2024
Limit of Indemnity
$1,000,000
Management Liability
Date Business Star
ted Trading
Tuesday, October 8, 2024
First location of where the business is conducted within New Zealand
wellington
Business Activities Conducted At This Location
stuff
Owned/Leased
Owned
Do you have any locations or contracts to work outside of New Zealand?
Yes
Please provide details
gfhjkl
Is the business currently able to meet its debts as they fall due?
Yes
Do you require the Insolvency Exclusion to be removed?
No
Do you manufacture the products you sell?
Yes
Product #1 designed by:
dfhgjh
Specifications by
dxgfchjk
Are any of your products used as components of, or incorporated or mixed into, any other products produced by any other parties?
Yes
Do you sell products in New Zealand?
Yes
Product #1
dwefgh
Actual turnover last financial year NZD
12345
Estimated turnover current financial year NZD
2345
Do you export products
Yes
Do you service or repair any third-party property?
Yes
Please provide full details
waesdfgh
Do you have third-party property in your care, custody or control?
Yes
Please provide full details
waefg
Nature of work #1
asdfg
Percentage of annu
al turnover
Does any of your work involve cutting, welding, or the use of naked flames or open heat sources?
No
Do you use, store, handle, manufacture or transport any acids, bulk liquids, chemicals, explosives, gases or any flammable, hazardous or toxic goods or substances?
No
Type of hazardous or toxic substance #1
asdfghvbn
Quantity
asdf
How used/stored/transported
wartf
Do you provide professional, technical or consultancy services or advice to your customers?
Yes
Please provide full details
qawgh
Do you charge a fee for these professional services
Yes
Please advise total fees from your last financial year.
wayt
Professional Indemnity Proposal
Professional Indemnity Limit
$1,000,000
Specify Limit of Indemnity
345
Retroactive Professional Indemnity Date
Friday, October 11, 2024
Personnel by category
Please indicate the number of personnel by
category
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 |
Business Details
Outline the nature of the business including a full description of your activities and in particular those activities where you provide professional advice, design or opinion which may be relied upon by a third party.
adfgfhgj
Activity 1
345
Percentage %
34
Details
sdfghj
Number of years the business has been operating?
34
Number of locations in New Zealand
34
Do you have contracts to work outside New Zealand?
Yes
Has the business name ever changed?
Yes
Have you ever acquired another business or merged with another business?
Yes
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 |
First Name
2345
Last Name
2345
Age
ws
Professional qualifications
wert
Date Qualified
Tuesday, October 8, 2024
Number of years with this firm
2
Number of years with previous firm
4
Are any of the principals, partners or directors financially or otherwise associated with any other business?
No
Please provide details
asdfghvbj
Please list the professional bodies or associations to which you belong
asdfgh
What arrangements do you have to assist you during your temporary absence on business, leave or sickness, or unforeseen emergency?
asedrftgh
Do you undertake any work which would involve you in manufacturing, construction, erection or installation?
No
Please provide details
asdfgh
Do you undertake any work which would involve you in the supply of materials, plant, goods, or equipment?
No
What proportion of the fees declared relates to such contracts?
wert
Does the supply relate to branded products only?
No
Do the products originate from suppliers outside New Zealand?
No
Please provide details of products and name and location of suppliers
awseghj
1. Particulars
warfty
Contract value/fees
23
Year
2. Particulars
sdfgh
Contract value/fees
234
Year
2345
3. Particulars
awerghj
Contract value/fees
234
Year
234
4. Particulars
asdfghj
Contract value/fees
234
Year
2345
5. Particulars
asdfgh
Contract value/fees
2345
Year
2345
Does any one client account for more than 50% of the business annual income?
Yes
Client name
wafghj
Nature of services provided to the client
wes
Income received from the client
ewrtyhjh
Does the business provide written reports to clients?
Yes
Are verbal reports always confirmed in writing?
Yes
Do you engage consultants, subcontractors or agents?
No
Do you insist they carry their own Professional Indemnity Insurance?
No
Do you enter into any hold harmless agreements or otherwise waive any legal rights or entitlements which you may have against such consultants, subcontractors or agents?
Yes
Do you use a stand
ard contractual ag
reement when engag
ing independent co
nsultants or contr
actors?
Yes
Do you use a standard contractual agreement for the supply of your professional services?
Yes
Please advise which percentage of your fees or turnover is outsourced to subcontractors
wgh21345
Has the business or any principal, partner or director ever been refused insurance of the type proposed, had a similar policy cancelled or had special terms imposed?
Yes
Please provide details
234565y
Has the business, any partner, principal, director or staff member ever been the subject of disciplinary proceedings for professional misconduct?
No
Please provide details
23456yt
Has any claim(s) ever been made against the business, its predecessors, or against any present or past principals, partners or directors?
No
Date of claim 1 or loss 1
Monday, October 7, 2024
Brief description of claim or loss
asdfgh
Cost of claim paid or loss insured (if any)
345
Estimated outstanding loss
2345
Is the matter finalised or outstanding?
Finalised
What action has been taken to prevent a recurrence of the situation which gave rise to this claim or loss?
asedfhgj
Potential Claims
Are any of the pri
ncipals, partners
or directors aware
, after enquiry of
all staff, manage
rs and contractors
, of any facts or
circumstances whic
h may give rise to
a claim or claims
of the type insur
ed by this policy?
Yes
| 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 |
Are any of the principals, partners or directors aware, after enquiry of all staff, managers and contractors, of any accounts overdue for payment where there is reason to believe that the client is dissatisfied with the professional services rendered?
No
Please provide details
wadfgh
Have you ever withdrawn a claim?
Yes
Please provide details
asdfghjb
Cyber Liability
Limit of Cyber Liability Indemnity
$1,000,000
Is all personally identifiable and confidential information that is removed from your premises in any electronic format encrypted? (e.g. USB, flash memory, disk hard drive, tape or other means?)
Yes
Do you regularly update (at least monthly) firewalls and virus protection software in place within your networks?
Yes
Do you have a Business Continuity Plan (BCP) which includes back-ups stored off-site, in place that is tested at least annually?
Yes
Do you have proced
ures for verifying
destination bank
accounts and/or an
y changes to desti
nation bank accoun
t details, before
funds are transfer
red?
No
Do you hold an approved list of vendors and suppliers, including authorised contact people and contact details, which is checked when payments are made?
Yes
Cloud / Back-up / Web Hosting
Yes
Name of Vendor
asdfg
Internet Service Provider (ISP)
Yes
Name of Vendor
asdfg
Business Critical Software Provider
Yes
Name of Vendor
asdfg
Data Processors (e.g. payment processing)
Yes
Name of Vendor
asdfg
POS Hardware Provider
No
Name of Vendor
asdfg
Managed Security Services (e.g. firewall, intrusion detection, anti-virus)
Yes
Name of Vendor
asdfgh
During the past 5 years has any claim been made, or have any circumstances which may give rise to a claim, against any entity or individual to be insured by this insurance been notified to insurers?
No
Please provide full details
asdfgh
Are there any circumstances not already notified to insurers which may give rise to a claim against any entity or individual to be insured by this insurance?
Yes
Please provide full details
asghj
Has any principal
or staff member ev
er been subject to
disciplinary proc
eedings, regulator
y action, or inves
tigation by any Go
vernment, regulato
ry or administrati
ve agency?
Yes
Material Damage
Please provide full details
asdfgh
Natural Disaster Cover Required
Yes
Stock/Other Property Anywhere in New Zealand
Yes
Sum Insured
23456
Money Section A
Wording Cover
Amount
2345
Money Section B
Wording Cover
Amount
23456
If the FEL is calculated on the indemnity value of the insured property and not the sum insured and a valuation of less than 2 years old has not been provided, has a declaration as prescribed by the Fire and Emergency Act been received for the current policy period?
Yes
Total Declared Indemnity Value of Property Insured excluding Stock and excluding "Stock/Other Property Anywhere in New Zealand"
e56t
Location One's Address
Address number
Occupation
sadfg
Building description
asdfg
Date of last valuation (Building)
Friday, October 25, 2024
Date of last valuation (Plant)
Tuesday, October 1, 2024
Year of Construction
Wednesday, October 23, 2024
Strengthening (% o
f the 2004 buildin
g code)
34 -
67%
Main Structural Framing
Reinforced Masonry
Wall Construction
Double Brick
Floor Construction
Wood
Roof Construction
Fibro
Number of Storeys
3
Does the building contain sandwich panels e.g Chiller units, spray booths
Yes
% of Insulated sandwich panels
1234
Burglar Alarm Type
Audible
Fire Detection System
Unmonitored smoke
Monitored smoke
Unmonitored heat
Automatic Sprinkler type
Dual Supply
Date of last certification
Wednesday, October 9, 2024
Towns/Main Water Supply
Yes
Is 50% of more of the building floor area unoccupied?
Yes
Number of residential units in the building (for EQC calculation)
3
Are there any interested parties to note?
Yes
Interested party name
sadfghv
Covers required
Contents
Seasonal Stock Increase
Sum insured for Buildings
sdfgh
Stock Sum insured
awesgh
Basis of Contents Settlement
Reinstatement
Contents Sum insur
ed
awesghj
Seasonal Stock Increase Limit (%)
asdfgh
Start date day of the month
2345
Locations Two's Address
Address number
Occupation
2345t6y
Building description
23456t
Date of last valuation (Building)
Tuesday, October 15, 2024
Date of last valuation (Plant)
Tuesday, October 8, 2024
Year of Construction
Friday, October 4, 2024
Strengthening (% of the 2004 building code)
34 - 67%
Main Structural Framing
Timber
Wall Construction
Brick Veneer
Floor Construction
Earth
Roof Construction
Reinforced Concrete
Number of Storeys
7
Does the building contain sandwich panels e.g Chiller units, spray booths
No
% of Insulated sandwich panels
2345
Fire Detection System
Unmonitored smoke
Automatic Sprinkler type
Dual Supply
Date of last certification
Monday, October 14, 2024
Towns/Main Water Supply
Yes
Is 50% of more of the building floor area unoccupied?
Yes
Number of residential units in the building (for EQC calculation)
3
Are there any interested parties to note?
No
Interested party n
ame
Covers required
Stock
Indemnity Period (Unless otherwise stated) in months
354
Business Interruption
Loss of Insured Profit / Revenue
Yes
Cover type
Profit
Indemnity Period (Months)
354678
Sum Insured
3546576
Loss of Rent
Yes
Indemnity Period (Months)
354678
Loss of Rent Sum Insured
e54678
Claim Preparation Costs
Yes
Sum Insured
5465768
Additional Increased Cost of Working
Yes
Indemnity Period (Months)
35467
Sum Insured
35467
Rewriting of Records
Yes
Sum Insured
546576
Payroll
Yes
Indemnity Period (Months)
546
Sum Insured
6457
Payroll / Wages - Dual Basis
Yes
Cover Type
Payroll
Indemnity Period [
months]
Sum Insured
tyuyi
Initial Period [weeks]
6578
Remainder of Period %
6578
Alternative Period [weeks]
5677
Wages in Lieu of Notice
Yes
Sum Insured
54657687
Notice Period [weeks]
354657
Book Debts
Yes
Sum Insured
24354678
Redundancy Pay
Yes
Sum Insured
w4e5r67
Redeployment Expenses
No
Indemnity Period [months]
e465768
Sum Insured
465789
Penalty Payments
Yes
Sum Insured
64578
Key Money
Yes
Sum Insured
tert6798
Do you wish to specify any Uninsured Working Expenses?
Yes
Uninsured Working Expense Name
465789
Commercial Motor
Large Losses > $50,000
Nil in the last 3 years
Ever been charged
with any breach of
regulations relat
ing to work time d
riving hours or lo
g book rules?
Yes
Had any convictions or had any penalties imposed for driving under the influence of alcohol or drugs?
Yes
Had a driver's licence cancelled or suspended or restricted?
Yes
Been convicted or charged with any driving offences or traffic infringements (other than parking offences or speeding)?
Yes
Cover Option
Third party, fire, and theft
Sum Insured
35467890
Year
3546
Make
5346576
Model
e54678
Type
Fire Appliance
Area of Operation
Waikato
Use
Civil Contracting
Sub-use
Architectural, Engineering, Surveying
Claims Grade
Grade 3 - 2 at fault claims in the last 3 years or no previous insurance history
Interested Parties
Names
fdghjkl
Loss of use
Yes
Maximum Limit Per Day
54657687
Maximum Period of Loss for any Vehicle(in Days)
43567
Portable Electronic Equipment
Yes
Details
rtuyiopo
Limit Per Item
4567
Number of Items
354678
About this template
Related templates
Employee Remote Work Policy Template
Outline your company policies for remote work. Drag and drop to customize your form. Works on any device. Desktop, tablet, and mobile friendly. Converts to PDF.
Smoke and Vape-Free Workplace Policy Template
Create a smoke-free workplace policy for a healthier work environment. Download responses as PDFs. Works on Android and iOS devices. Easy to customize.
Social Media Policy Template
Create a social media policy document in seconds with Jotform Sign. E-sign from any device. Easy to customize and share. Converts to a PDF document.
School Student Parent Handbook and Code of Conduct
Create a student-parent handbook to set school guidelines. Easy to customize. Works on all devices — Android and iOS. Send, sign, and store.
Employee Code of Conduct Template
Create a professional code of conduct to send to your employees. Can be signed from any smartphone, tablet, or computer. Easy to customize and share. No coding.
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.