Strata Insurance Application Form - IMC Insurance Brokers

Your Details

Name*

First Last

Address*

Street Address Suburb State Postal Code

Contact Number*

Email*

Details of the Risk

Owners Corporation/Plan of Subdivision Number:*

Is the property Professionally managed?*

Please specify strata manager details*

Property Address*

Street Address Suburb State Postal Code

Current Insurer*

Renewal Date

Valuation

Has the building been valued for insurance purposes?*

Date of Valuation*

Valuation Amount ($):*

Building Sum Required ($)*

Should you require higher amounts for Loss of Rent or Common Contents, please include your amended figures • Loss of Rent is automatically calculated at 15% • Common contents is automatically calculated at 1%

Optional : Loss of Rent (15% of Building sum insured): $

Optional : Contents (1% of Building sum insured): $

Optional Catastrophe Cover:

Paint and Wallpaper? (NSW & ACT only)

Floating floorboards?

Flood required?

The following are not included automatically and are optional benefits of which you can request to be included in the quotation

Section 2 – Voluntary Workers Personal Accident

Weekly/Capital benefit Included: $2,000 / $200,000

Section 3 – Office Bearers' Liability

Limit of Liability (including Defence costs):*

Do you require additional Defence costs?*

Section 4 – Fidelity Guarantee

Fidelity: Insured

Section 5 - Equipment Breakdown (Engineering Cover Including Loss of Rent)

Option 1 – Limit of liability is the Building Sum Insured or $20 million, which is the lesser*

Option 2 – Sub-limited cover (Residential only)*

Number of lifts/escalators etc:*

Car stacker/s:*

Chillers:*

Section 6 – Public Liability

Limit of liability ($):*

Section 7 – Government Audit Costs, Workplace Health and Safety Breaches and Legal Expenses

7A – Audit Costs, 7B – WH&S, 7C – Legal Expenses: Insured

Loss History

Any losses in the past 5 years? (including below excess):*

Details*

Date of Loss (DD/MM/YYYY)

Description

Amount

Closed? (Y/N)

In order for us to provide you the most competitive price, it is important that we have full disclosure of all losses in the past five years. Please attach a copy of the claims history on letterhead from the current insurer, even if there have been no losses.

Max. file size: 1 GB.

Excess

Current standard excess ($):

Malicious Damage - optional ($):

Tropical Cyclone - optional ($):

Flood - optional ($):

Other ($):

General Declarations

Any claims declined?*

Any insurance declined?*

Any excesses imposed?*

Any defects?*

If you have answered Yes to any of the questions above, please provide details*