Your Name (required)
Your Phone Number (required)
Your Email (required)
Your ABN (where applicable)
Situation
Occupation
Due Date
___________________________________________________________________________________________________________________
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
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?
Is the insured a property owner?
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:
