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admin
2019-09-17T21:38:58+10:00
1
Your Details
2
Property Details
3
Sum Insured
4
Underwriting Information
Insured Details
Contact Name
*
Insured Name
*
ABN
Telephone Number
*
Email
*
Street Address
*
Address Line 2
Suburb
*
State
*
Please select
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
*
Business Details
Describe your main activities
*
Estimated Annual Turnover
*
Employee Numbers(F/T basis)
*
Industry Experience
Please select
1 - 5 Years
5 - 10 Years
10 - 20 Years
20 years +
Policy Start Date
Month
Day
Year
Property Details
Address of premises to insured
*
Approximate age of premises or year built
*
Please select
Before 1945
1945-1965
1965-1985
1985-1995
1995-2005
2005-2015
2015-Current
Walls
*
Please select
Brick
Concrete
Aluminium
Iron/Steel
Steel on a Steel frame
Steel on a Timber frame
Tile
Fibro/Asbestos
Fibro
Glass
Timber
Canvas
Other
Floor
*
Please select
Brick
Concrete
Aluminium
Iron/Steel
Steel on a Steel frame
Steel on a Timber frame
Tile
Fibro/Asbestos
Fibro
Glass
Timber
Canvas
Other
Roof
*
Please select
Brick
Concrete
Aluminium
Iron/Steel
Steel on a Steel frame
Steel on a Timber frame
Tile
Fibro/Asbestos
Fibro
Glass
Timber
Canvas
Other
Fire extinguishers / hose reels
*
Yes
No
CCTV
Yes
No
Sprinkler System
Yes
No
Smoke detectors
Yes
No
Sum Insured
Please choose the insured items you require from below options:
Property Damage
Yes
No
Building Sum Insured
*
Contents, Equipment, Fitout and Stock
*
Flood Cover
Yes
No
Business Interruption
Yes
No
Gross Profit
*
Indemnity period
*
Please select
6 months
12 months
18 months
24 months
Burglary/Theft
Yes
No
Sum Insured
*
Money Theft
Yes
No
Sum Insured
*
Glass Cover
Yes
No
Internal Glass
Yes
No
External Glass
Yes
No
Public Liability Insurance
Yes
No
Limit of Liability
Machinery Breakdown
Yes
No
Machinery Value
Please select
$10,000
$20,000
$30,000
$40,000
$50,000
Other
Deterioration Stock
Other
Underwriting Information
Have you been convicted of any criminal offence within the past 5 years (other than minor traffic convictions)?
*
Yes
No
Please provide the date of offence and details
*
Have you been liable for any civil offence or pecuniary penalty (exceeding $5000)?
*
Yes
No
Please provide the date of the offence and details
*
Have you made any claims on an insurer for loss or damage?
*
Yes
No
Please provide the date, cause, cost and further details
*
Have you had any insurance declined or cancelled, proposal or application rejected, renewal refused, claim rejected, special conditions or excess imposed by an insurer?
*
Yes
No
Please provide the date, cause, cost and further details
*
Have you suffered any loss or damage which would have been covered by the proposed insurance policy?
*
Yes
No
Please provide the date, cause, cost and further details
*
Have you or your partner(s) or director(s) of the business ever been declared bankrupt?
*
Yes
No
Please provide the date and any further details
*
Have you or your partner(s) or director(s) of the business ever been involved in a company or business which became insolvent or subject to any form of insolvency administration (eg. Liquidation or receivership)?
*
Yes
No
Please provide the date and any further details
*
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Please upload any supporting information and documents
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Accepted file types: jpg, pdf, doc, docx, png, gif, Max. file size: 20 MB, Max. files: 10.
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