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: *

Period of Insurance From: *

Period of Insurance To: *

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: *

If you have answered Yes please provide details (when, what for, how much): *

Building Construction, Fire Protection and Security

Walls *

Floor *

Fire Sprinklers *

Windows *

Roof *

Fire Alarms *

External Doors: *

Burglary Alarms: *

Public Liability Section

Level of Cover: *

Excess: *

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 *

Fire & Perils Section

Building Sum Insured: *

Contents Sum Insured: *

Stock Sum Insured: *

Business Interruption

Indemnity Period: *

Floor Level: *

Gross Income: *

Theft Section

Combined Contents & Stock: *

Money Section

Combined Money: *

Glass Section

External Glass cover required: *

Glass Exposure: *

Contents: *

Is Internal Glass cover required: *

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: *

If YES, cover is not available.

Indicate the sum insured required for Taxation Investigation: *

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: *

Signature: *

Date: *

How did you hear about us? *

Word of mouth Internet/Google Advertising We contacted you

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