Referrer Business Name
Referrer Contact
Referrer Phone Number
Referrer Email
Client Business Name (if applicable)
Client Contact Name
Client Contact Number
Best Time to Call
ASAP Any Morning Afternoon Evening
Insured Name
Insured Name 2 (if applicable)
Trading Name
Business Occupation
ABN
Postal Address
Email Address
Have you ever alone or in partnership or jointly with any other party or, if a corporation, the corporation or any of its directors:
a. Suffered any loss(es) (insured or otherwise) totalling more than $5,000 in the last 12 months or totalling more than $10,000 in the last three (3) years or suffered two (2) or more claims in any one policy year?
YES NO
b. In the last five (5) years had any insurer decline any claim or proposal, cancel or refuse to renew a policy, or increase the premium or impose special conditions?
YES NO
c. In the last five (5) years ever been placed in receivership or liquidation or declared bankrupt?
YES NO
d. In the last 10 years been convicted of or had any fines or penalties imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property?
YES NO
Building occupied by (business type or profession)
Construction of premises
Brick / concrete WITH sprinklers Brick / concrete WITHOUT sprinklers Combustible walls WITH sprinklers Combustible walls WITHOUT sprinklers
Security of premises
No security Office Block with 24 hour security Shopping Centre with 24 hour security Deadlocks / swipecards WITH Alarm Deadlocks / swipecards WITHOUT Alarm
Locality
Industrial Estate Main Street Suburban Street
Fire:
1. Building sum insured
2. Contents sum insured
3. Stock sum insured
Theft:
1. Contents / stock sum insured
2. Tobacco / alcohol sum insured
Money:
1. Transit / Business Hours
2. In safe
3. Outside Business Hours
Glass:
1. External
2. External and Internal
3. Internal
General Property - place total sum here and itemise in next field
Itemise General Property and amount per item here
Business Interruption:
1. Type of Cover
Gross Profit Gross Income
2. Indemnity Period
6 months 12 months
3. Turnover
Public & Product Liability:
1. Sum insured
2. Turnover
3. Do you export to North America
YES NO
4. Are you a property owner only
YES NO
Additional comments or questions
