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Business Insurance Form
General information
*Required
Legal Entity:
*
*
Indicates required field
Trading Name:
*
ABN:
*
Name
*
First
Last
Phone Number
*
Email
*
Website:
*
Address
*
Line 1
*
Line 2
*
State
*
Postcode
*
Country
*
Occupation:
*
Occupation Description:
*
Total number of employees:
*
Date business Established:
*
Date format: 01/01/0000
Period of Insurance From:
*
Date format: 01/01/0000
Period of Insurance To:
*
Date format: 01/01/0000
Claims Information
In the past five (5) years, have you, or anyone else insured by the policy:
- Lodged more than (3) claims for loss, or
- Had claims made against you, or
- Lodges claims totalling more than $5,000?
Claims:
*
- Please select -
Yes
No
If you have answered Yes please provide details (when, what for, how much):
*
Building Construction, Fire Protection and Security
Walls
*
- Please select -
Brick/Concrete
Aluminium/Fibro/Iron/Steel
Glass/Canvas
Polystyrene
Other
Floor
*
- Please select -
Concrete
Wood
Other
Fire Sprinklers
*
- Please select -
None
Dual Water Supply
No Sprinklers
Windows
*
- Please select -
No ground level opening windows
Locks/Bars/Grilles on ground level opening windows
Locks/Bars/Grilles on some ground level opening windows
Roof
*
- Please select -
Concrete
Glass/Canvas
Polystyrene
Tile, Iron, Fibre/Asbestos (on steel frame)
Tile, Iron, Fibre/Asbestos (on timber frame)
Other
Fire Alarms
*
- Please select -
Automatic Fire Alarms
No Alarms
Smoke Detector
External Doors:
*
- Please select -
No Deadlocks
Deadlocks on all external doors
Burglary Alarms:
*
- Please select -
No Alarm
Local Alarm
Monitored Alarm
Monitored Alarm/security patrol response
Monitored Alarm/security response/reg
Public Liability Section
Level of Cover:
*
- Please select -
5,000,000
10,000,000
20,000,000
Other
Excess:
*
- Please select -
$500
$1,000
$2,500
$10,000
Other
Estimated Annual Turnover:
*
$
Does the business: (answer below)
Engage personnel provided through labour hire companies or organisations?
Undertake welding or hot cutting activities away from own premises?
Perform work at mine sites, either above or below ground?
Provide products or services intended for use in the mining industry?
Provide equipment on hire?
Assume liability under any agreement other than property rental agreements
Import any products into Australia?
Export any products to the USA or Canada?
Select one
*
- Please select -
Yes
No
Fire & Perils Section
Building Sum Insured:
*
Contents Sum Insured:
*
Stock Sum Insured:
*
Business
Interruption
Indemnity Period:
*
- Please select -
3 months
6 months
9 months
12 months
18 months
24 months
Floor Level:
*
- Please select -
Ground floor only
Above ground floor only
Ground floor plus one or more additional floors
Two (2) or more floors above ground floor
Gross Income:
*
$
Theft Section
Combined Contents & Stock:
*
Money Section
Combined Money:
*
Glass Section
External Glass cover required:
*
- Please select -
Yes
No
Glass Exposure:
*
- Please select -
Minor Glass Exposure
Medium exposure, building/showroom less than 50sqm
Large exposure, building/showroom greater than 50sqm
Contents:
*
Is Internal Glass cover required:
*
- Please select -
Yes
No
Stock:
*
Machinery Breakdown
Machinery Limit Per Event:
*
Item 1: Description of Property (make and model) and Sum Insured
*
Item 2: Description of Property (make and model) and Sum Insured
*
Item 3: Description of Property (make and model) and Sum Insured
*
Item 4: Description of Property (make and model) and Sum Insured
*
Item 5: Description of Property (make and model) and Sum Insured
*
Deterioration of Goods - Frozen:
*
Deterioration of Goods - Unfrozen:
*
Tax Investigation
Has the ATO served general notification that it will be carrying out audit of your industry:
*
- Please select -
Yes
No
If YES, cover is not available.
Indicate the sum insured required for Taxation Investigation:
*
- Please select -
$10,000
$20,000
$30,000
$40,000
$50.000
Accountants Name:
*
Other Sections
Additional Sections Available:
*
DECLARATION
This declaration must be completed and signed by or on behalf of the party applying for insurance. I/We
a) declare that:
i. the answers and information given by me/us in this Application are true and correct in all respects;
ii. no information has been withheld that would affect an insurer's decision to accept this Application;
iii. where answers in this online application have not been completed by myself, they have been checked by me/us and I/we agree they are correct and true;
iv. I/we have read and understood the
Financial Services Guide
and
Privacy Statement
;
v. if there was insufficient space to fully answer any questions, I/we have attached supplementary pages providing the additional information required.
b) authorise National Insurance Group Pty Ltd to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to these insurance covers, and any other insurances held by me/us and claims under those insurances.
Upload additional information or a copy of your current insurance here:
*
Max file size: 20MB
Please send all correspondence by email:
*
- Please select -
Yes
No, send by regular post
Signature:
*
Date:
*
How did you hear about us?
*
Word of mouth
Internet/Google
Advertising
We contacted you
Submit
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