MGA Contractors & Trades - Plumbers Insurance Declaration

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

About You
Do you trade as a

Do you trade as a Company (Pty Ltd) Sole-Trader Other Other
Please confirm your business name
Please confirm your business address
Other than Plumbing (including associated activities), do you perform any other services?

Other than Plumbing (including associated activities), do you perform any other services? Yes No
Please describe other services you provide
What is your estimated turnover for the following 12 months? Delete
What is your estimated turnover for the following 12 months?
How many skilled Employees do you have engaged in the business?
On average, how many Sub-Contractors do you have engaged in the business
What percentage of your income is generated by work performed by Sub-Contractors
What is your estimated payments to Sub-Contractors for the following 12 months - delete
What is your estimated payments to Sub-Contractors for the following 12 months
Please confirm your estimated payments to sub-contractors
What percentage of your income is generated by the use of Hot Works (Welding Equipment, Blow Torches, Hot Air Guns etc)
Do you perform any work over 10 metres or 3 stories?

Do you perform any work over 10 metres or 3 stories? Yes No
Do you perform Type B Industrial Gas Fitting Services?

Do you perform Type B Industrial Gas Fitting Services? Yes No
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 12 months?

Been declared bankrupt or had a financial interest in a business that has been declared bankrupt, put into receivership or liquidation within the last 12 months? 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?

Had any liability insurance cancelled or non renewed, or made a claim for Public Liability that you have not already disclosed to MGA? 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 5 years?

Been prosecuted under any health and safety legislation or similar laws in the past 5 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 - Plumbers Insurance Declaration

MGA Contractors & Trades - Plumbers Insurance Declaration

About You

Duty of Disclosure

Declaration