Step 1 of 5 20% Business Name*Business Address* Street Address Suburb Post Code Business Type*RetailHospitalityHair & BeautyServicesManufacturingTradesOfficeOtherWebsite Your Name* First Last Contact Phone*Email Address* General InformationHave you or any partner(s) or director(s) of the business (in the past five years)Made any claim(s) on an insurer for loss or damage?SelectYesNoPlease provideInsures NameType of LossAmount ClaimedDate of Loss Had any insurance declined or cancelled, proposal/application rejected, renewal refused, claim rejected, special conditions or excess imposed by an insurer?SelectYesNoPlease provideDateInsurerReason Been convicted of a criminal offence or ever delcared bankrptcySelectYesNoPlease provide*DateDetails Details of the Business/PremisesPlease provide the following details:Year Property BuiltHow much Expanded Polystyrene (EPS) does the premises contain (e.g. foam insulation)?Select0%1-14%15-19%20-29%30% or moreFloor constructionSelectConcreteIron/SteelBrickWoodOther/Mixed (non combustible walls)Other/Mixed (combustible walls)OtherWallsSelectConcrete/StoneConcrete tilt slabIron/Steel/Aluminium on steelIron/Steel/Aluminium on woodBrickMasonryExpandable Polystyrene (EPS)WoodGlassMetalMixed <75% Brick/Concrete/Iron on steelMixed >75% Brick/Concrete/Iron on steelOtherRoofSelectConcreteMasonryTiles/SlateAsbestosFibroIron/Steel/Aluminium on steelIron/Steel/Aluminium on woodExpandable Polystyrene (EPS)WoodGlassAge of BuildingAre you:SelectThe tenantAn owner occupierThe owner of the premisesHow long do you own the business?How long do you own the property?Is there any cooking on the premises?SelectYesNoPlease describe type of cookingDo you use a Deep Fryer?SelectYesNoHow many litres (capacity)*Fire Extinguishers?SelectYesNoPlease specify how many fire extinguishers*Fire Hoses?SelectYesNoPlease specify how many fire hoses*Fire Sprinkler System?SelectYesNoDeadlocks on all External Doors?SelectYesNoBars/Grills on all External Windows?SelectYesNoBurglar Alarm System?SelectYesNoAlarm Type?SelectLocal Alarm OnlyLocal Alarm with Dialler24 hour Monitored AlarmMonitored By Property SectionSum insured : (Replacement Value)Do you require cover for Fire & Specified Perils?SelectYesNoBuildingContents Including StockLoss of RentRemoval of DebrisBusiness Interruption SectionSum InsuredDo you require cover for Business Interruption?* No Yes Gross Income (Estimated for the next 12 months)*Indemnity Period (months)Theft SectionSum InsuredDo you require cover for Burglary?* No Yes All Contents (Excluding tobacco, cigarettes & cigars)Stock in Trade (Excluding tobacco, cigarettes & cigars)Stock in Trade (Including tobacco, cigarettes & cigars)Money SectionSum Insured Do you require cover for Money?* No Yes Money on premises during business hoursMoney on premises outside business hoursMoney on premises (in locked safe or strongroom)Money at private residenceDo you require cover against Damage to Safe/StrongroomMachinery Breakdown SectionDo you require cover for breakdown of machinery, plant, boilers and pressure vessels?* No Yes Machinery ListType of equipmentHP - Motor Size Deterioration of Refrigerated StockElectronic Equipment SectionDo you require cover for Electronic Equipment Breakdown Yes No Electronic EquipmentDescription / NameReplacement Value Restoration of Data (Max $30,000)Glass SectionDo you require cover against Glass breakage Yes No External Glass Yes No Please select premises typeSingle Glass PaneDouble Frontage GlassMulti Panel GlassInternal Glass Yes No Broadform Liability SectionHow many people including working partners/directors are employed in the business?Estimated Turnover (next 12 months)EmailThis field is for validation purposes and should be left unchanged. Δ
