APPLICATION TO BECOME A MEMBER

Full name of employer

Note - if the employer is a company or other body, please give the full legal name of the body.

Postal address of employer

Employer's email address

Employer's phone number

Street address of business premises

Note - if the premises are in more than one location, please specify each location.

Nature of trade or business

Proprietor / Principal Officer

Period of cover required from

Period of cover required to (at 4pm)

Do you use machinery?

Do you use, store or handle acids, gases, chemicals, explosives or radioactive materials?

Will any members of your family who reside with you be employed in your trade or business?

Note - a "member of your family" means a child under 18; a child aged 18 or over but under 25 who is engaged in full-time education or training; a child aged 18 or over who is, because of mental or physical infirmity, unable to support himself or herself; a parent; a spouse (including de facto spouse).

Only answer "yes" to this question if the family member resides with you.

A family member who is your employee, and who resides with you, is not covered under the public scheme unless the above question is fully answered.

Have you previously effected insurance with an insurance company?

Has any insurer permitted withdrawal of, or declined, any proposal?

Please give details

Has any insurer cancelled or refused to renew a policy?

Please give details

Number of full-time employees

Note - a full-time employee is one who works for 35 or more hours per week.

Number of part-time employees

Note - a part-time employee is one who works for less than 35 hours per week.

Performing clerical work

Supervising manual work

Performing manual work

Using powered machinery

The employer named above hereby applies to the executive member for membership of the public scheme. The employer named above hereby declares that the information provided above is true.

Date