Your Information Name*
First
Last
Address*
Current Insurance Do you currently have Business insurance?
Business Details How many years has this business been in operation?*
What states does your business receive income from?* If Overseas, please advise further details*
Business Activities Please describe your business activities and/or occupation*
Cover Options What covers would you like quoted?*
Property Damage Cover How many locations do you have?*
Location 1 Location 1 - Address Details*
Interested Party Information Do you wish to note any Interested Party for this location?* If yes, what is the nature of interest?* Address of Interested Party
Location 1 - Building Details
Is the premises more than 50% vacant?* Is the building heritage or national trust listed?*
Is the premises connected to town water?* Does the building have Expanded Polystyrene (EPS)?* If yes, what percentage of the walls contain this product?*
Number of stories?*
Where are the premises located?*
Type of fire brigade servicing property:*
Do you store flammable liquids at the premises?* If yes, please provide further details*
Are substances stored in accordance with Australian Standards and local / state government regulations?* Are goods stored in approved cabinets and/or storage facilities*
Location 1 - Construction Details
What are the floors made of?*
What are the external walls made of?*
What is the roof made of?*
Location 1 - Security / Fire Safety Equipment
Fire protection provided?* Does the sprinklers cover 100% of the property?* Do the sprinklers conform to Australian Standards?* Is the water supply:*
Security at premises?*
Please specify the type of monitored alarm*
Location 1 - Cover Required
Do you require Flood cover for Location 1?*
Location 1 - Cover Required Tick all that you require
Are there multiple buildings on the site to be insured?* If yes, please provide more details*
Specified Item(s) details*
If other, please provide further details
Location 2 Location 2 - Address Details*
Interested Party Information Do you wish to note any Interested Party for this location?* If yes, what is the nature of interest?* Address of Interested Party
Location 2 - Building Details
Is the premises more than 50% vacant?* Is the building heritage or national trust listed?*
Is the premises connected to town water?* Does the building have Expanded Polystyrene (EPS)?* If yes, what percentage of the walls contain this product?*
Number of stories?*
Where are the premises located?*
Type of fire brigade servicing property:*
Do you store flammable liquids at the premises?* If yes, please provide further details*
Are substances stored in accordance with Australian Standards and local / state government regulations?* Are goods stored in approved cabinets and/or storage facilities*
Location 2 - Construction Details
What are the floors made of?*
What are the external walls made of?*
What is the roof made of?*
Location 2 - Security / Fire Safety Equipment
Fire protection provided?* Does the sprinklers cover 100% of the property?* Do the sprinklers conform to Australian Standards?* Is the water supply:*
Security at premises?*
Please specify the type of monitored alarm*
Location 2 - Cover Required
Do you require Flood cover for Location 2?*
Location 2 - Cover Required Tick all that you require
Are there multiple buildings on the site to be insured?* If yes, please provide more details*
Specified Item(s) details*
If other, please provide further details
Location 3 Location 3 - Address Details*
Interested Party Information Do you wish to note any Interested Party for this location?* If yes, what is the nature of interest?* Address of Interested Party
Location 3 - Building Details
Is the premises more than 50% vacant?* Is the building heritage or national trust listed?*
Is the premises connected to town water?* Does the building have Expanded Polystyrene (EPS)?* If yes, what percentage of the walls contain this product?*
Number of stories?*
Where are the premises located?*
Type of fire brigade servicing property:*
Do you store flammable liquids at the premises?* If yes, please provide further details*
Are substances stored in accordance with Australian Standards and local / state government regulations?* Are goods stored in approved cabinets and/or storage facilities*
Location 3 - Construction Details
What are the floors made of?*
What are the external walls made of?*
What is the roof made of?*
Location 3 - Security / Fire Safety Equipment
Fire protection provided?* Does the sprinklers cover 100% of the property?* Do the sprinklers conform to Australian Standards?* Is the water supply:*
Security at premises?*
Please specify the type of monitored alarm*
Location 3 - Cover Required
Do you require Flood cover for Location 3?*
Location 3 - Cover Required Tick all that you require
Are there multiple buildings on the site to be insured?* If yes, please provide more details*
Specified Item(s) details*
If other, please provide further details
If more than 3 locations, please provide details of covered required here.*
Business Interruption Cover What type of Business Interruption cover do you need?* Please click on each cover to get a definition of what it means.
Indemnity Period to Insure* Select multiple options if you want different quotes
Do you want to include cover for your payroll?* How many weeks do you want to insure your payroll?* Do you want to include cover for your Loss of Rent that your business normally recieves?*
Indemnity Period to Insure* Select multiple options if you want different quotes
Indemnity Period to Insure* Select multiple options if you want different quotes
Additional Increased Costs of Working
Business Interruption Cover - Other cover options Do you want to insure the Goodwill in your business?
Do you want to note any Uninsured Working Expenses*
Uninsured Working Expenses
If yes, please provide further details*
Do you wish to specify any Customers and/or Suppliers?*
Specified Customers and Suppliers
If yes, please provide further details*
Theft Cover What do you need to protect from theft?* Please provide details of Specified Items to be insured*
Please provide details of Other Items to be insured*
Security Details Security at premises?*
Please specify the type of monitored alarm*
Public Liability Cover Level of Cover Required*
NSW Stamp Duty Declaration Are you a small business Individual / Partnership / Company and/or Trust, which is carrying on a business, and the business has an aggregated turnover of less than $2 million* Aggregated turnover is your Australia wide annual turnover plus the annual turnovers of any business entities that are your affiliates or are connected with you.
Do you regularly work away from your usual business location?* Is your business involved with any of the following?* Please provide further details of this work*
Contractors & Labour Hire
subcontractor is engaged as part of an overall contract for which the insured is providing goods or services.
contractor would be people of entities who are engaged to carry out work for the insured, which would not be “directly” related to their business.
Labour Hire provider is a business that has an arrangement in place with one or more individuals to supply the individuals to perform work in and as part of a host’s business or undertaking and is obliged to pay the individual for the work performed for the host.Do you engage contractors or subcontractors for any of your work?* Type of work Contractors undertake on your behalf?*
Do you ensure that contractors and/or subcontractors have their own liability and where necessary, Workers Compensation insurance?**
Do you enter into contracts with each and every contractor?* If not, please explain why there is no contract*
Do all contracts have an indemnity or waiver of subrogation in your favour?* If not, please provide further details*
Do you hire out any employees to third parties on a Labour-Hire basis?* What activities will they undertake?*
Products Cover With regards to Products, do you*
Are any of your products used in or at*
Do you have quality control procedures in place for all of your products?* Have you ever recalled a product because of a potential safety hazard?*
Manufactured Products Can you identify the source of every item used in their Manufacture?*
Imported Products
Do you modify Products that you Import?* If yes, please provide further details*
Exported Products
Do you modify Products that you Export?* If yes, please provide further details*
Repackaged Products
Other than Re-Packaging, do you modify these Products in any way?* If yes, please provide further details*
Distributed Products
Do you modify Products that you Distribute?* If yes, please provide further details*
Contract Liability Have you or will you sign any contracts (Other than for a property lease)*
If you have or will be signing a contract, will you assume liability or hold any party harmless*
Portable Equipment Cover What items do you need to insure?*
Specified Items Please provide a list of items to be insured, including value of each item*
A rough value for items that are to be covered as unspecified Portable Equipment*
Limit required for any one loss*
Money Cover What Money cover is required?*
Glass Cover Glass to insure
Glass Exposure* If other, please advise further details*
Floors occupied*
If other - specified glass, please advise further details*
Machinery Breakdown Cover Please provide an overview of the insurable Plant and Machinery*
Limit of any one loss sum insured required*
Do you need to insure any specified Plant & Machinery item?* If yes, please provide further details*
Do you need to insure for Deterioration of Stock?* If yes, please provide further details*
Electronic Equipment Breakdown Cover Limit of any one loss sum insured required*
Do you need to insure any specified Electronic Equipment item?* If yes, please provide further details*
Electronic Equipment - Part B Business Interruption Cover
Do you want to include Part B - Business Interruption cover?*
Indemnity Period to Insure* Select multiple options if you want different quotes
Tax Audit Cover Cover type required* Sum insured required*
Director / Owner details*
Has the business &/or any director had any previous Tax Audits?* Has the ATO advised the business &/or any director that it intends to carry out an audit?*
Has the ATO provided a general notification to your industry that it will be carrying out audits of your industry?* Have you ever been investigated by the ATO or Office of State Revenue, with this investigation resulting in a fine, penalty, criminal charges or a conviction?*
Employee Dishonesty Cover To your knowledge, have any of your employees been charged with, or convicted of, a criminal offence relating to dishonesty, fraud, theft or embezzlement in the past 5 years?* Are all accounting practices and functions of the business (including cash book entries, petty cash handling, balance in hand and any other records of monies received) subject to an independent check at least monthly?* If yes, please provide further details*
If yes, please provide further details*
Is the accounting function of your business subject to an annual independent audit?*
In which states are your employees based?*
Sum insured required for any one incident:* Please select all options you would like quoted.
Annual limit of liability required (maximum for all incidents in a 12 month period):* Please select all options you would like quoted.
Goods in Transit Cover Please provide an overview of the items to be sent*
Do you transport any temperature controlled goods?* If yes, please provide details of items sent*
Type of cover required* Sum insured required for any one incident:* Please select all options you would like quoted.
Management Liability Cover Sum insured required* Please select all options you would like quoted.
Do you require Employee Dishonesty coverage?*
In the last 5 years have there been any claims made against the compant or its directors &/or employees which may have been covered under this policy section if it were in force?* In the last 5 years, has the company suffered any direct financial loss exceeding $5,000 as a result of fraud or dishonesty committed by a staff member?* If yes, please provide further details*
If yes, please provide further details*
Other Cover If other coverage is required, please provide further information as to your requirements*
Duty of Disclosure
YOU in the questions below relates to your Firm, Company or you as a Sole Practitioner including present or former Partners, Directors, Principals, Consultants, or Employees.Have YOU ever had an insurance policy cancelled, declined or special terms imposed?* Have YOU ever been declared bankrupt?* If yes, please provide further details*
If yes, please provide further details*
Have YOU ever been involved in a company or business which became insolvent or subject to any form of insolvency or voluntary administration (e.g. liquidation or receivership)?* Have YOU ever been convicte of any criminal offence within the past 5 years (other than minor traffic convictions)?* If yes, please provide further details*
If yes, please provide further details*
Have YOU been liable for any civil offence or pecuniary penalty (exceeding $5,000)?* Have YOU got any other matters to disclose?* If yes, please provide further details*
If yes, please provide further details*
Have YOU ever had proceedings (civil or criminal) instigated alleging misconduct or breaches of the law in their capacity as a director or officer of the company?* Are YOU aware of any facts that may give rise to a claim or of any facts that a reasonable person may think may lead to a direct financial loss as a result of fraud or dishonesty of a staff member, against the company or its directors?* If yes, please provide further details*
If yes, please provide further details*
Claims History In the past 3 years, under the sections of cover to be insured, have there been any claims &/or uninsured losses, &/or circumstances of which could give rise to a claim?* If yes, please provide further details*
Other Insurances Do you require a quote on any other insurance?* If other, please advise details*
Important Information
Please tick all to confirm that you have read the following documents:*
Signature 
