Equipment Insurance Application Form

Name*

First Last

Address*

Street Address Suburb State Postal Code

Contact Number*

Email*

Start Date*

Expiry Date*

Insured Name*

First Last

ABN

Trading Name

Business Occupation

Location of Risk*

Any claims in the last 3 years?*

Claim Details:*

Date of Incident: (DD/MM/YYYY)

Description of Incident:

Claim Settlement Amount ($) :

Specified Items*

Description:

Serial Number:

Sum Insured ($) :

Do you require cover for Unspecified Items?*

Total Sum Insured:*

Note: Unspecified Items are covered up to $3,000 per item. Any items valued above $3,000 will need to be specified above.