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Business Insurance Application Form  
   
Policy No Client No
Intermedairy No  
 
   
THE APPLICANT/S
Name(s) in full   
Tax status Registered Business Yes No ABN Taxable
Postal Address State Postcode
Contact Numbers
Phone No. (Private) Phone No. (Business)
Fax No. Email:
Other Interested Persons
(e.g. Morgagees or Lessors) -
Name and Address
State Postcode
Period of Insurance
From     to          at 4 pm
 
   
GENERAL INFORMATION
(If "Yes", to any questions below, please provide full details including name of insurer, dates, amount in $'s, reason for cancellation) Please Tick
 
a) Have you(in the past five years)

     1. made any claim(s) on an insurer for loss or damage?
Yes No
     2. had any insurance declined or cancelled, proposal/application rejected, renewal refused, claim rejected, special conditions or excess
     imposed by an insurer?
Yes No
     3. suffered any loss or damage which would have been covered by the proposed insurance policy?
Yes No
 
b) Have you or any partner(s) or director(s) of the business

     1. ever been declared bankrupt?
Yes No
     2. Ever been involved in a company or business which became insolvent or subject to any form of solvency administration (e.g. liquidation
     or receivership)?
Yes No
     3. been convicted of any criminal offence within the past 5 years (other than minor traffic convictions)?
Yes No
     4. been liable for any civil offence or pecuniary penlty?
Yes No
 
   
DETAILS OF THE BUSINESS/PREMISES
Type of Business or Property Owner only
Activities or Processes Involved
or Property Owner only
Location(s) If same as postal address  
State Postcode
State Postcode
Construction of Premises        Walls Floors Roof No. of Storeys Age of Building
Occupation Code    
Construction Code  
Survey Details Yes No        Date
A survey/inspection of your premises may be required. Please supply the name and contact telephone number of the appropriate
contact person, with whom an appointment can be made.

Name:           Phone No.
Number of Years
In this business            At this location
Occupancy
Are you the Owner of Premesis An Owner Occupier or a Tenant
Where you are the Owner of a multi-tenanted property,
please show
Location 1 Location 2
Name Occupation Name Occupation
1. 1.
2. 2.
3. 3.
4. 4.
5. 5.
6. 6.
7. 7.
8. 8.
9. 9.
If more please attach a list.
Changes in tenancies and the types of business must be notified to us in writing as they occur.
Failur to do so may effect your entitlement to claim benifits in the event of loss or damage.

N.B. You must advise us if any unit is unoccupied in excess of 60 days.
Fire and Theft Protection

Installed and Maintained at
the Premises
In this section of premesis occupied solely by you protected by:                     Location 1 Location 2
1. Connection to Mains Water Supply? Yes No Yes No
2. Fire Sprinkler System? Yes No Yes No
3. Fire Extinguishers? Yes No Yes No
4. Fire Hoses? Yes No Yes No
5. Deadlocks on all External Doors? Yes No Yes No
6. Bars/Grills on all External Windows? Yes No Yes No
7. Burglar Alarm System? Yes No Yes No
Type: Local Siren only Yes No Yes No
24hr: monitored Yes No Yes No
 
   
PROPERTY SECTION
Interest Insured
SUM INSURED
Location 1 Location 2
Building
Contents Including Stock
Rent Payable for a period up to
Removal of Debris (Instead of the automatic $5,000)
You Cover under this section includes Accidental Damage for 10% of the Sum Insured to a Maximum of $50,000.
If increase of cover required please show amount.
Is the policy to motgagee Protection Only? (Property Section only to apply) Yes No Yes No
 
   
BUSINESS INTERRUPTION SECTION
Interest Insured
SUM INSURED
Location 1 Location 2
Gross Income (Money payable to you for goods sold/services rendered or rentals, less purchase cost of stock)    
Indemnity Period Months
or or
Weekly Income          Indemnity Period Months
Claims Preperation Costs (Instead of Automatic $5,000)
Outstanding Accounts Receivable
Additional Increased Cost of Working
TOTAL SUM INSURED
 
   
THEFT SECTION
Interest Insured
SUM INSURED
Location 1 Location 2
Stock in Trade (Excluding tabacco, cigaretts & cigars)
Tabacco, Cigaretts & Cigars
Contents (replacement value)
Claims Preperation Costs (Instead of Automatic $5,000)
Theft from office (Instead of automatic $2,000)
Other (specify)   
TOTAL SUM INSURED
 
   
MONEY SECTION
Interest Insured
SUM INSURED
Location 1 Location 2
Money in transit
Money in buildings during business hours
Money in buildings outside business hours (Maximum allowable $5,000)
Money in buildings whilst contained in locked safe or strongroom
Money at your employees residence (Maximum allowed $5,000)
Damage to Safe/Strongroom
 
   
MACHINERY BREAKDOWN SECTION
Note: Fire and Perils risks are to be insured under the Property Section. Theft risks are to be insured under the theft section.
Do you require cover for LIMIT OF
INDEMNITY   
RATE
%
   1. Breakdown of Machinery, Plant, Boilers and pressure vessels?    Yes No     $5,000
Deterioration of Refrigerated Goods (max $5,000)
Note: i) If your machinery answer is 'Yes', Please complete the following list by showing the number of each type of equipment at all locations shown on the schedule.
ii) No plant must exceed 4Kw/5hp.
Plant List No. Plant
Factor
Factor
Total
Air Conditioning Equipment
Split System 11
Window/Wall Type 2
Commercial Refrigeration
Equipment
Freezers/Soft Serve Machine 11
Temprites 4
Other Units 9
Kitchen Equipment
Dish or Glass Washers 1
Exhaust Fans (Inc. Canopy) 1
Microwave Ovens 1
Slicing, Mincing, & Mixing
Equipment
1
Laundry Equipment
Washers, Extractors, Dryers 1
Plant List No. Plant
Factor
Factor
Total
Misc. Equipment
Air Compressor 6
Auto Car Washer 15
Car Hoist 4
Cash Register/Scanning Equpiment 2
Coffee Machine 2
Electronics Scales 2
Engine Diagnostic Unit 10
Pump (noc) 1
Refrigerant Reclaimer 8
Vacuum Cleaners 2
Wheel Aligner/Balancer 3
Work Shop plant (noc) 3
Total Plant
Factor Nos
 
   
Electronic Equipment Section
Note: i) Fire & Perils risks are to be insured under the Property Section. Theft risks are to be insured under the Theft Section.
ii) Maximum limit $30,000 any one item and $250,000 in all.
iii) Indemnity Period 3 months, Excess 2 working days for Increased Cost of working cover.
List items (including make, model and serial numbers) SUM INSERTED
(New replacement cost $)
Rate
%
Restoration of Data (Max $30,000)
Increased Cost of Working (Max $30,000)
TOTAL SUM INSURED
 
   
BROADFORM LIABILITY SECTION
LIMIT OF INDEMNITY
Location 1 Location 2
a) How many people including working partners/directors are employed in the business?
b) Gross Annual Wages paid (Include commission and other earnings)
d) Where you require indemnity as Property Owner Only, please show
-Total Area of Premises in square metres
-Replacement Value of Building
-General Describtion of Occupancy i.e. Retail, Offices, Industrial, Residential, etc.
e) Additional Covers available (please show amount when cover required)
    1) Testing and/or Delivery of vehicles (Limit any one vehicle)
    2) Property (excluding registered vehicles) in your physical and legal control (instead of the automatic $10,000) (Maximum $50,000)
    3) Garages (Vehicles in custody excluding driving risk)
f) About your products (NOte - Exports to USA/Canada are not covered)
    1) Do you sell or distribute any product of a type not normally accociated with your business/occupation? Yes No
    2) Do you manufacture, pack or relable any products which you sell or distribute? Yes No
    If "Yes" show %         Manufacture         Pack         Relable
    3) Do you import products or raw materials? Yes No
If "yes" from which countries?
    4) Are your products manufactured to comply with any Federal or state regulation or recognised International Standard Code? Yes No
 
   
GLASS SECTION
INTEREST INSURED Location 1 Location 2
Internal Glass Yes No Yes No
External Glass Yes No Yes No
General description of Occupancy, Factory, Warehouse, Retail, Office
Size of Largest Pane of Glass
Additional Cover in excess of $3,000 for Temporary Protection and Shattering, Signwriting, Shopfronts, Damage to Property
and Damage to Electric Signs
 
   
GOODS IN TRANSIT SECTION
Applies to goods in a vehicle owned/operated only by you SUM INSURED RATE %
Limit of indemnity per trasit
Will transits include tobacco, cigaretts or cigars? Yes No
 
   
GENERAL PROPERTY SECTION
List items (including make, model and serial numbers) for which Australia wide Accidental Loss or Damage
cover is required
SUM INSURED RATE %
TOTOAL SUM INSURED
 
   
EXCESS OPTION
A reduction in premium can be obtained should you choose to bear one of the following excess choices.
Please tick your selection
Exceess $500 or Excess $1,000
N.B. These excess amounts when selected apply to all selections of the policy thaht are operative (except Broadform Liability for bodily injury claims).
 
  
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