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      Business Insurance Form

      General information                                                                   *Required

      Date format: 01/01/0000
      Date format: 01/01/0000
      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?

      Building Construction, Fire Protection and Security

      Public Liability Section

      $

      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?

      Fire & Perils Section

      Business Interruption

      $

      Theft Section

      Money Section

      Glass Section

      Machinery Breakdown

      Tax Investigation

      If YES, cover is not available.

      Other Sections

      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.

      Max file size: 20MB
    Submit

    National Insurance Group
    ABN:  94 219 052 354

    Authorised Representative: 1265061
    of McLardy McShane Partners Pty Ltd 
    AFSL No: 232987
    ​ABN: 14 064 465 309
    National Insurance Group endorses the Insurance Brokers Code of Practice. To obtain a copy of the code, click here.


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    Disclaimer :The information provided by National Insurance Group on this website is for general information purposes only, and it is not a substitute for professional advice.  You should always consider the PDS/Policy wording before making a decision.  Coverage may differ based on specific clauses in individual policies.  Refer to the FSG on our website or by requesting a copy for our services and remuneration details.
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