The Insured's Details Your Name (required) Your Phone Number (required) Your Email (required) Your ABN (where applicable) Situation Occupation Due Date ___________________________________________________________________________________________________________________ General Details Construction Walls: Floors: Roof: Number of Levels: Age: Fire Protection ExtinguishersHose ReelsFire BlanketsSprinklerSmoke DetectorsFire HydrantsOther Security Alarm With: Please SelectBack to BaseLocalGrills OnDoorWindowDeadlocksPatrolSafe Name of Current Insurer Has Renewal Been Offered Please SelectYesNo ____________________________________________________________________________________________________________________ Claims History Last 5 Years Number and Incurred Costs Years in Business: Operators Industry Experience: Cooking facilities and Deep Fryers: Has the insured ever had any insurance declined or cancelled? YesNo Has the insured ever been charged with a criminal offence or declared bankrupt? YesNo Is the insured a property owner? YesNo ____________________________________________________________________________________________________________________ Sum Insured Details Property Buildings: Contents (excluding stock): Stock: Cigarettes/Tobacco/Cigars: Liquor/Alcohol: Rent Payable: Removal of Debris: Accidental Damage: Business Interruptions Gross Profits: Claims Preparation Costs: Accounts Fees: Loss of Rent: Indemnity Period (years and months): Theft Stock (excluding tobacco): Tobacco/Cigarettes/Cigars: Contents and Stock: Alcohol/Liquor: Other: Money In Transit: On Premises (Bus. Hours): On Premises (After Hours): In Safe: At Private Residence: Damage To Safe: Type of Glass: SingleFrontDouble FrontMulti Front Glass Internal: Glass external: Lightbox / Signs: Machinery and Plant Items: Deterioration of Frozen Food: General Property Description of Items: Cover For: Fire, TheftAccidental Damage Public and Products Liability Limit - Public Liabilty: Limit - Products Liabilty: Limit - Property Owners: Number of Permanent Staff: Number of Casual Staff: Turnover: Gross Wages Paid: Testing and delivery of vehicles limit: Goods in care custody and control: Additional Information: