INSURED'S - Details

  Business Name*

  Business Address*

 City/Town*

Post Code*

  Postal Address*

 City/Town*

Post Code*

Occupation*

Annual Turnover*

$  

No of Staff*

Import/Export?

    No Yes   (does your business import or export goods?)

PREMISES - Details

 Construction of Walls

Brick/Concrete Other

 Construction of Floors

Concrete Other

 Construction of Roof

Brick/Concrete Iron/Tile Other

 Sprinkler System

 Hydrant/Hoses

 Extinguishers

 Security Alarm

No Alarm Local Monitored

 Fire Alarm

 Deadlocks on external doors

 Connected to Town Water

Yes No

 Sandwich Paneling

No Yes

 Key locks &/or Bars on Windows

 Do you have/use a deep fryer

No Yes if yes, how many units   and the size of each unit No Deep Fryer 1 Litre 2 Litre 3 Litre 4 Litre 5 Litre 6 Litre 7 Litre 8 Litre 9 Litre 9 Litre 10 Litre 11 Litre 12 Litre 13 Litre 14 Litre 15 Litre 16 Litre 17 Litre 18 Litre 19 Litre 20 Litre Above 20 Litre

 INSURANCE – Details

Building

$

Contents

$

Stock & Customers Goods

$

Rewriting of Records

$

Removal of Debris

$

Other

$ if other please provide details:

Contents

$

Stock &/0r Customers Goods

$

Cigs, Tobacco or Liquor

$

Other

$ if other please provide details:

Other

$       if other please provide details:

GLASS

Glass Breakage Cover - Not Required Internal Only External Only Internal and External

MONEY

Loss of Money Cover - Not Required $1,000 $2,000 $3,000 $4,000 $5,000 $10,000

PORTABLE ITEMS Tools, Laptops, etc

$

TAX INVESTIGATION

Tax Investigation Cover - Not Required $10,000 $20,000 $30,000 $40,000 $50,000

LIABILITY

$5,000,000 $10,000,000 $20,000,000 Liability Cover - Not Required

Customers Goods

$

Do you conduct any welding

No Yes

ELECTRONIC EQUIPMENT BREAKDOWN

Computers & Electronic Breakdown Cover - Not Required Breakdown Required

 PREVIOUS INSURANCE - Details

  Have you ever suffered any losses or claims

No Yes

  Have you ever had any insurance cancelled or declined or special terms imposed?

No Yes  

  Have you ever been charged or convicted of any criminal offence or declared bankrupt?

No Yes  

  Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?

No Yes  

 CONTACT – Details

First Name*

Surname*

  Phone No

   (please include area code)

  Fax No

   (please include area code)

Email Address*

How did you find us?*
---Please Select--- American Vehicle Sales Better Buying Group Building Commission Building Industry Solutions Building Inspector Conveyancer Fair Trading Dept NSW Friend or Family Member Google Search Government Department Im a Existing CGIB Client Insurance Broker Insurance Company Internet Search Steadfast White Pages www.ownerbuilder.net.au Yellow Pages Book Yellow Pages Online Other if other, please provide details

 * Mandatory Fields

Thanks for completing our online form.

We will endeavour to contact you with your insurance details soon.

Meanwhile, if you require any further assistance please feel free to contact us.

We may need to contact you to obtain additional information to assist us in providing you with a Business Insurance Quotation.

Completion of this form does not put an insurance policy/cover in place - you will need to contact us to arrange insurance cover.

All information you provide must be correct, true, and accurate as incorrect or misleading information may alter our quote and jeopardise cover if you proceed with a policy.

We recommend that you read the relevant Product Disclosure Statement when considering an insurance policy.