MGA Contractors & Trades - Painters Insurance Declaration

Items marked with * are required. You MUST fill them in before you can submit.

About You
Are you currently insured with MGA Insurance Group?

Are you currently insured with MGA Insurance Group? Yes, I am renewing an existing policy with MGA No, I would like a new quote
Please confirm the level of cover / sum insured required

Please confirm the level of cover / sum insured required 5,000,000 10,000,000 20,000,000
Do you trade as a

Do you trade as a Company (Pty Ltd) Sole-Trader Other
Please confirm your business name
Please confirm your business address
What year did your business commence?
Other than Painting & Decorating (including associated activities), do you perform any other services?

Other than Painting & Decorating (including associated activities), do you perform any other services? Yes No
Please describe other services you provide
What state is your business based?
PLEASE NOTE
NSW STAMP DUTY EXEMPTION FOR SMALL BUSINESS (NSW BASED BUSINESSES ONLY)

If you are based in NSW and your annual turnover is less than $2,000,000, your Stamp Duty will be waived under the NSW state government exemption. To confirm if you are exempt, please review the guidelines provided in our fact sheet HERE
Are you a business based in NSW with a turnover of less than $2,000,000 and would like to claim the Stamp Duty exemption?

Are you a business based in NSW with a turnover of less than $2,000,000 and would like to claim the Stamp Duty exemption? Yes No
NSW Stamp Duty Declaration
I declare that at the time this policy is renewed, I am/will be a ‘small business’ as defined in section 259A of the Duties Act 1997 (NSW):

I declare that at the time this policy is renewed, I am/will be a ‘small business’ as defined in section 259A of the Duties Act 1997 (NSW): Yes No
I have read and understand the Guidance provided with this Declaration and do not have any questions:

I have read and understand the Guidance provided with this Declaration and do not have any questions: Yes No
What is your estimated turnover for the following 12 months?
What is your estimated turnover for the following 12 months?
How many skilled Employees do you have engaged in the business? (this does not include Sub-Contractors or Labour Hire)
On average, how many Sub-Contractors do you have engaged in the business
On average, what are your Annual Payments to Sub-Contractors or Labour Hire firms per year?
What percentage of your income is generated by work performed by Sub-Contractors
What % of your works involves performing outdoor spray painting?
Will you work at external heights greater than 20m?

Will you work at external heights greater than 20m? Yes - we will apply to have no height restrictions applied, however an additional premium will apply (typically 15%). No - your policy will include a $25,000 Excess for Incidental work over 20m.
Please describe the type & value of work you perform at heights over 20m
Do you perform any Rope Access work?

Do you perform any Rope Access work? Yes No
Please describe the type & value of work you perform via Rope Access
What percentage of your income is generated by the use of Hot Works (Welding Equipment, Blow Torches, Hot Air Guns etc)
Duty of Disclosure

Has the Business or any partner or director or any other person responsible for managing the business:
Ever been convicted (or charged but not tried) with any offences excluding “possession” (dealing/trafficking) of marijuana, minor criminal offences not involving assault, molestation, stalking, and fraud, provided these did not occur within the last 5 years?

Ever been convicted (or charged but not tried) with any offences excluding “possession” (dealing/trafficking) of marijuana, minor criminal offences not involving assault, molestation, stalking, and fraud, provided these did not occur within the last 5 years? Yes No
Please provide more details about convictions/charges
Been declared bankrupt or had a financial interest in a business that has been declared bankrupt, put into receivership or liquidation within the last 3 years?

Been declared bankrupt or had a financial interest in a business that has been declared bankrupt, put into receivership or liquidation within the last 3 years? Yes No
Please provide more details
Had any liability insurance cancelled or non renewed, or made a claim for Public Liability that you have not already disclosed to MGA in the past 3 years?

Had any liability insurance cancelled or non renewed, or made a claim for Public Liability that you have not already disclosed to MGA in the past 3 years? Yes No
Please provide more details regarding cancellation, non renewals or claims
Been prosecuted under any health and safety legislation or similar laws in the past 3 years?

Been prosecuted under any health and safety legislation or similar laws in the past 3 years? Yes No
Please provide more details about any prosecutions
Declaration
Your name
Your email address
Your contact phone number
Do you understand that the information provided in this declaration form part of your insurance contract, and any information that is not true or correct may lead to any claim being reduced or denied on the basis of non-disclosure of a material fact?

Do you understand that the information provided in this declaration form part of your insurance contract, and any information that is not true or correct may lead to any claim being reduced or denied on the basis of non-disclosure of a material fact? Yes No
My declaration

My declaration I declare that all of my answers above are true and accurate

MGA Contractors & Trades - Painters Insurance Declaration

MGA Contractors & Trades - Painters Insurance Declaration

About You

PLEASE NOTE NSW STAMP DUTY EXEMPTION FOR SMALL BUSINESS (NSW BASED BUSINESSES ONLY)

NSW Stamp Duty Declaration

Duty of Disclosure

Declaration

PLEASE NOTE
NSW STAMP DUTY EXEMPTION FOR SMALL BUSINESS (NSW BASED BUSINESSES ONLY)