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Business Insurance QuotE FORM

Details
Public Liability
Contents and Building
Theft Cover
Glass
Business Interruption
Machinery Breakdown
Money
Tax Audit
Electronic Equipment Cover
Transit Cover
Portable Equipment
General information

Employees (Business owner included)

Estimated Annual Revenue (Australian Dollars)

$

Street Address

Email address

First name

Last name

Phone Number

Start date of Insurance:

Do you want your quote to include?

Public Liability

Yes No

Building and Contents

Yes No

Theft

Yes No

Glass

Yes No

Business Interruption

Yes No

Machinery Breakdown

Yes No

Money

Yes No

Tax Audit

Yes No

Electronic Equipment

Yes No

Portable equipment

Yes No

Transit Cover

Yes No

Does Your Business engage or intend to engage non-clerical contractors, subcontractors, or staff from labour hire firms to perform work under the sole or partial direction of You?

Yes No

Does the business directly import raw materials, components or finished goods?

Yes No

Would you like to note your landlord as an interested party on your Public Liability policy?

Yes No

Is EPS or any other form of insulated sandwich panel present within the building?

Yes No

Construction of the External Walls?

Construction of all the Floors?

Construction of the Roof?

Sum Insured – Building

$

Are there fire extinguishers and fire blankets in place and serviced every 6 months?

Yes No

Are the Premises connected to town water and in the area of a permanently manned Fire Station?

Yes No

Do the Premises comply with Fire and Council regulations?

Yes No

Replacement Value - Stock in Trade

$

Replacement Value - Customers Goods

$

Would you like to name an interested party for your property cover?

Yes No

Theft Insured Amount – Contents

$

Theft Insured Amount – Stock

$

Theft Insured Amount – Tobacco

$

Replacement Value – Liquor

$

Have you had any claims for theft?

Yes No

Is your property in a Retail or Office building with after hour security and no external access?

Yes No

Do you have any illuminated signs?

Yes No

Largest pane of glass

Have you had any claims for glass?

Yes No

Are the premises fully enclosed in a shopping mall or complex?

Yes No

Gross Income

$

Additional Increase Cost Of Working

$

Claims Preparation Costs

$

Outstanding Accounts Receivable

$

Are there any uninsured working expenses?

Yes No

Indemnity Period

6 months 12 months 24 months

Number of Machinery Breakdown claims in the last 12 months?

Item Type

Description

Do you require cover for Deterioration of Stock?

Yes No

Have you had any claims for money?

Yes No

Sum Insured

$

Sum Insured - Tax Audit

$

Please add items to insure

Item

Description

Year Purchased

Sum Insured

$

Restoring Data Cost

$

Cost of Working

$

What is the maximum value of any single trip:

$

What is the total value of all trips in a calendar year:

$

Number of Portable Equipment claims in the last 3 years?

Please add items to insure

Item

Make & Model

Serial Number

Sum Insured

$

Had any business insurance/liability claims?

Yes No

Had any insurance declined or cancelled?

Yes No

Suffered any loss or damage which would have been covered by the proposed insurance policy?

Yes No

Been convicted of any criminal offence?

Yes No

Been liable for any civil offence or pecuniary penalties?

Yes No

Been declared bankrupt or involved in a business which became insolvent?

Yes No

As at today's date does the insured have Public Liability or Business Insurance currently in force that has been paid for?

Yes No

Email address

Contact Details

Kew East

Level 1, Suite 5
796 High Street
Kew East, VIC 3102

Mentone

83A Warrigal road, Mentone 3194

1800 078 078

Available
9:00 am - 5:00 pm

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