LinkedIn
Youtube

PAYMENT
ABOUT US
CONTACT US
NEWS
CLAIMS
1800 245 123

PERSONAL
BUSINESS
PROFESSIONAL
ASSOCIATIONS
INDUSTRIES
CLAIM
PAYMENT
CONTACT US
ABOUT US
Search
Menu Menu

CLAIM
PAYMENT
CONTACT US
ABOUT US
COMPLIANCE
PERSONAL
BUSINESS
PROFESSIONAL
ASSOCIATIONS
INDUSTRIES

Contract Works Staff Form

1. Contact/Business Details
Contact Name
Contact Phone
Email
Website
Number of Business Names
- 1
- 2
- 3
- 4
Business Name 1*
Business Name 2*
Business Name 3*
Business Name 4*
Street address
Suburb:
State
Postcode
Please provide details of business activities
2. Turnover
Estimated value of Insurable Projects to be commenced in the next 12 months ($)
Actual value of projects commenced in the past 12 months, so we can complete any adjustments to the coverage from last year. ($)
3. Limits of Cover
Awarded Contract Value
Unbroken Construction Period
Maintenance Period
4. Sums Insured
Sub limits are indicated. should you require a higher sum insured please indicate in the field
Section 1 - Contract Works Material Damage (any one occurrence)
Property Insured (any one contract)
Plant and Equipment (any one item of plant)
Existing Structure
Professional Fees
Removal of Debris
Govt expenses
Expediting Expenses
Claims Preparation costs
Temporary protection
Plans, documents and data
Search and Locate
Off-site Storage
Inland Transit
Mitigation Expenses
Section 2 - Third Party Legal Liability (any one occurrence)
General (unlimited in the aggregate)
Products (in the aggregate)
Contractors Pollution Liability
5. Construction Plant & Equipment
Minor Plant and Equipment
Welding equipment, air compressors, pumps, concrete mixing and batching equipment, reusable formwork, temporary buildings, scaffolding, etc.
Value must represent the total new replacement value of all plant and equipment owned by the Named Insured. Limit any one item of $5,000 to apply.
Major Plant and Equipment
Fixed and Mobile cranes, earth moving equipment or other similar construction plant. This specifically excludes any registered vehicles such as cars, sedans, utility vehicles, etc.
Value must represent the total new replacement value of all plant and equipment owned by the Named Insured.
Estimated Hiring Charges
Please provide an annual estimate of hiring charges likely to be incurred for the hire of Minor or Major Plant and Equipment.
6. Excess
Section 1 - Contract Works Material Damage (any one occurrence)
All claims
Section 2 - Third Party Legal Liability (any one occurrence)
All claims
Worker to Worker Liability
Contractors Pollution Liability
7. Proposed Works
Please estimate the type of works likely to be undertaken in the coming Policy Period (The total should equal 100%):
DOMESTIC DWELLINGS (new work)
DOMESTIC DWELLINGS (Refurbishment, Alteration or Additions)
APARTMENTS/UNITS (new work)
APARTMENTS/UNITS (Refurbishment, Alteration or Additions)
COMMERCIAL (new work)
COMMERCIAL (Refurbishment, Alteration or Additions)
INDUSTRIAL (new work)
INDUSTRIAL (Refurbishment, Alteration or Additions)
INSTITUTIONAL (new work)
INSTITUTIONAL (Refurbishment, Alteration or Additions)
OTHER (new work)
OTHER (Refurbishment, Alteration or Additions)
Please provide details of Other Works
TOTAL (Must equal 100%)
Please advise if you are likely to engage in any of the following:
- civil works (roads, runways, dams, silos, bridges, pipelines or railways)
- car parks or landscaping only projects
- earthworks/ site preparation only projects, i.e. without the associated building works
- swimming pools where such works are greater than 30% of the estimated Contract Value
- any works underground (other than for foundations, installation of building services and building basements)
- any works involving more than one basement and/or excavations deeper than 3 metres
- any works in, under or over water
- any works involved in the mining or power industry
- any use of explosives
- any demolition works greater than $50,000 or demolition works on structures greater than two storeys
- any underpinning, shoring, driven piling or lowering of the water table
- any proposed work involving buildings or structures that are heritage listed, trust listed or the like.
Please provide additional information.
8. Insurance History
Are you currently insured for contract works?
- Yes
- No
Have you ever been insured for contract works?
- Yes
- No
Name of Insurer
Due Date
Sum Insured
Excess
Premium
9. Past Applications
Have you ever had a Contract Work insurer:
Decline a proposal?
- Yes
- No
Decline to renew your insurance?
- Yes
- No
Impose special terms?
- Yes
- No
Cancel your insurance?
- Yes
- No
Please provide details
10. Claims History
During the past 10 years has any Claim been made, or has negligence been alleged, against any entity or individual to be insured by this insurance (including any prior corporate entity and any of the present or former Principals), or have any circumstances which may give rise to a claim against any of these been notified to insurers?
- Yes
- No
Nature of Problem
Insurer
Year notified
Claimant
Amount paid and/or outstanding
- Tick to add additional claim
Nature of Problem
Insurer
Year notified
Claimant
Amount paid and/or outstanding
- Tick to add additional claim
Nature of Problem
Insurer
Year notified
Claimant
Amount paid and/or outstanding
- Tick to add additional claim
Please add additional claims details (as per above)
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 (including any prior corporate entity and any of the present or former Principals).
- Yes
- No
Name of Practice and Principal
Claimant
Nature of Problem
Estimate
- Tick to add additional claim
Name of Practice and Principal
Claimant
Nature of Problem
Estimate
- Tick to add additional claim
Name of Practice and Principal
Claimant
Nature of Problem
Estimate
- Tick to add additional claim
Please add additional claims details (as per above)
Has any Principal or staff member ever been subject to disciplinary proceedings for professional misconduct?
- Yes
- No
Name of Practice and Principal
Claimant
Nature of Problem
Amount paid &/or Outstanding
- Tick to add additional claim
Name of Practice and Principal
Claimant
Nature of Problem
Amount paid &/or Outstanding
- Tick to add additional claim
Name of Practice and Principal
Claimant
Nature of Problem
Amount paid &/or Outstanding
- Tick to add additional claim
Please add additional claims details (as per above)
Hidden
12. Additional Client Comments
Any additional information given by client
Admin Details
Servicer
Transaction
Mfiles Reference Number (If Any)
Hidden
Add to Lead
Hidden
Lead created
Hidden
Renewal

ABOUT US

Our People
Community Involvement
News
Careers

COMPLIANCE

Financial Services Guide, Code of Practice,Privacy Policy, Terms of Engagement, GAW, Terms & Conditions
Other Policies
Complaints

SCORESBY HEAD OFFICE

Toll free: 1800 245 123
Phone: (03) 9835 1300
info@abcountrywide.com.au
Level 2, 35 Dalmore Drive
Scoresby VIC 3179

DROUIN OFFICE

Toll free: 1800 245 123
Phone: (03) 5625 1015
drouin@abcountrywide.com.au
3 Bank Place, Drouin VIC 3818

LEONGATHA OFFICE

Toll free: 1800 245 123
Phone: (03) 5662 4222
leongatha@abcountrywide.com.au
63 Bair St, Leongatha, VIC 3953

LinkedIn
Youtube

Staff Only

Scroll to top

You are about to leave our site

By purchasing online:

• You are expected to self-manage your policy.
• There is no advice provided by Austbrokers Countrywide.
• You will need to manage your own claims directly with COVERMORE by calling 1300 728 822.
• If you need to make changes to the policy, you will need to contact COVERMORE on 1300 728 822.

CLICK TO CONTINUE

You are about to leave our site

By purchasing online:

• You are expected to self-manage your policy.
• There is no advice provided by Austbrokers Countrywide.
• You will need to manage your own claims directly with CHUBB by calling 1800 803 548.
• If you need to make changes to the policy, you will need to contact CHUBB on 1800 803 548..

CLICK TO CONTINUE

You are about to leave our site

By purchasing online:

• You are expected to self-manage your policy.
• There is no advice provided by Austbrokers Countrywide.
• You will need to manage your own claims directly with EMERGENCE by calling 1300 799 562.
• If you need to make changes to the policy, you will need to contact EMERGENCE on 1300 799 562

CLICK TO CONTINUE

Please select your profession

1. Engineering & Construction Industry Project Manager

2. Information Technology Project Manager

3. Other Project Manager (including white collar, training, government, and change management)

You are about to leave our site

By clicking continue you will be directed to the Countrywide Advice Website.
Or call Countrywide Advice on 1300 991 479.

CLICK TO CONTINUE

Technology is great when it works… but painful when it doesn’t.
Don’t worry. We’re here to help.

Firstly, make sure you are using one of our recommended browsers – Firefox, Chrome or Safari.

PAGE IS UPLOADING BUT THERE’S NO FORM
OOPS! This is probably an issue at our end. Shoot us an email and we’ll fix it with a new link.

FORM IS VERY SLOW OR TIMING OUT
Please check your internet connection is running correctly. Try other websites to see if they work.
If that’s OK then our server is probably experiencing high traffic issues. Please try the following.

Click the ‘PREVIOUS’ button then the ‘NEXT’ button to reset.
Click the ‘Save & Continue this Application Later’ link. Use this link to continue the application at a later time.
Still no luck? Shoot us an email and we’ll sort it out.

FORM IS BEING BLOCKED BY A FIREWALL MESSAGE
We have protection in place to secure data but sometimes this can cause conflict with your security settings.
Let us know and we’ll give you an alternative link for the form.

We’d love your feedback to help us improve this process. Shoot us an email.

You are about to leave our site

By purchasing online:

• You are expected to self-manage your policy.
• There is no advice provided by Austbrokers Countrywide.
• You will need to manage your own claims directly with Austbrokers Life Solutions by calling 1300 161 635.
• If you need to make changes to the policy, you will need to contact Austbrokers Life Solutions on 1300 161 635.

Contract Works Staff Form

1. Contact/Business Details

2. Turnover

3. Limits of Cover

4. Sums Insured

Sub limits are indicated. should you require a higher sum insured please indicate in the field

Section 1 - Contract Works Material Damage (any one occurrence)

Section 2 - Third Party Legal Liability (any one occurrence)

5. Construction Plant & Equipment

6. Excess

7. Proposed Works

8. Insurance History

9. Past Applications

Have you ever had a Contract Work insurer:

10. Claims History

12. Additional Client Comments

Admin Details

ABOUT US

COMPLIANCE

SCORESBY HEAD OFFICE

DROUIN OFFICE

LEONGATHA OFFICE