Office Insurance Quote Request

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Your Information

Name*

Address*


Current Insurance

Do you currently have Office insurance?

What states does your business receive income from?*


Business Activities


Cover Options

What covers would you like quoted?*


Duty of Disclosure


The term 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?*

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 convicted of any criminal offence within the past 5 years (other than minor traffic convictions)?*

Have YOU been liable for any civil offence or pecuniary penalty (exceeding $5,000)?*
Have YOU got any other matters to disclose?*


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?*


Other Insurances

Do you require a quote on any other insurance?*


Important Information


Please take a moment to read these important documents prior to submitting your form.


Declaration

  • I/WE declare that we have read the important notices attached above and I/WE understand those notices.
  • I/WE undertake to inform insurers of any material alteration to these facts whether occurring before or after completion of the Contract of Insurance.
  • I/WE hereby acknowledge that the insurance cover may be provided in whole or in part by overseas insurers.

Please tick all to confirm that you have read the following documents:*


Signature


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