Please complete the following information and submit this form to obtain an insurance quotation for your business.

Click on one of the following link if you would like to obtain a quote for another type of insurance product.

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.

Please refer to the CGIB Financial Services Guide, Privacy Statement, General Advice Warning and Duty of Disclosure before completing this form.

INSURED'S - Details

  Business Name*

  Business Address*

 City/Town*

Post Code*

  Postal Address*

 City/Town*

Post Code*

  Occupation*

Please Select Accounting Services (incl Tax Agent and Bookkeeper) Actuary Advertising Services Architectural Services (incl drafting) Assessor Business Administrative Services (office only) (excl convention, exhibition, event management) Business Management Services (incl management consultants) (excl project managers) Call Centre and Phone Answering Service Chiropractic Services Commercial Art and Display Services (excl printing) Computer Consultancy Services Consulting Engineering Services Data Processing Services (not computer storage) Dental Services, Dentist, Orthodontist (not dental hospitals) Desktop Publishing Service (no printing) Employment Placement Services executive search, outplacement, vocational guidance only (excl Labour Hire Contractors) Financial Asset Broking Services incl Stock Brokers General Insurance General Practice Medical Services - Doctors Graphic Art / Design Service Health Insurance Health Services nec (chiropodist, occupational therapy, podiatrist, osteopath) Health Services nec (massage, X-ray, dietician, homeopaths, naturapath, reflexology) Health Services nec (prosthetists, orthotists) Insurance Broker Interior decorating service (excl storage) Interpreter Legal Services (incl Solicitor and Barrister) Life Insurance Market Research Services Marketing Consultant Mortgage Broker Other Financiers Pathology Services Physiotherapy Services Psychologist Public Relartions Consultant (excl events) Real Estate Agents (conveyancing, land brokers, title searching, valuers, rental agents, property managers) Real Estate Agents (excl conveyancing, land brokers, title searching valuers,rental agents, property managers) Residential Property Operators Secretarial Services Services to Finance and Investments nec (financial advisors) Specialist Medical Services Strata Managers Surveying Services Travel Agency Services (excl tour guides) Veterinary Services (incl animal hospitals)(excl quarantine)  

Occupation - Other

Annual Turnover*

No of Staff

Please Select 1 - 5 6 - 10 11 - 20 21 - 30 31 - 40 51 - 60 61 plus  

ABN Number

PREMISES - Details

 Construction of Walls

Please Select Brick/Concrete Other

 Construction of Floors

Please Select Concrete Other

 Construction of Roof

Please Select Brick/Concrete Iron/Tile Other

 Sprinkler System

 Hydrant/Hoses

 Extinguishers

 Security Alarm

Please Select No Alarm Local Monitored

 Fire Alarm

 Deadlocks on external doors

 Key locks &/or Bars on Windows

 INSURANCE – Details

Building

Contents

Rewriting of Records

Removal of Debris

Other

Business Interruption

  (Annual Gross Profit)

Additional Increase Cost of Working

Claim Preparation Fees

Other

Glass

Please Select Not Required Yes

Money

Please Select Not Required $1,000 $2,000 $3,000 $4,000 $5,000 $10,000

Portable Items Laptops, etc

Tax Investigation

Not Required Please Select $10,000 $20,000 $30,000 $40,000 $50,000

Liability

Please Select Not Required $5,000,000 $10,000,000 $20,000,000

Computers/Electronic Equipment

Please Select Breakdown Not Required Breakdown Required

 PREVIOUS INSURANCE - Details - MUST COMPLETE ALL QUESTIONS

  If "YES", Please provide the date your existing policy expirers* Please Select 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Not Insured / Please Select Jan Feb March April May June July Aug Sept Oct Nov Dec Not Insured / Please Select 2009 2010 2011 2012 2013 2014 2015 2016 Not Insured

  Have you ever suffered any losses or claims?

Please Select No Yes - Provide Details Below

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

Please Select No Yes - Provide Details Below  

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

Please Select No Yes - Provide Details Below  

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

Please Select No Yes - Provide Details Below  

 CONTACT – Details

First Name*

Surname*

  Fax No

Email Address*

*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 provide you with an 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.