Commercial Products Fact Find
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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 |
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 |
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 |
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 |
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