INSURED'S - Details

  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?)

 INSURANCE – Details

LIABILITY

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

Customers Goods

$

Do you conduct any welding

No Yes

 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 Public Liability 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.