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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: