1a. Business Name:*
1b. Business Address :*
1c. Type of Business:*
1d. Number of Staff*
1e. Annual Wages Paid:*
1f. Gross Turnover / Annum*
1g. Building occupied by
-- Choose --
Proposer
Tenant
Proposer and Tenant
1h. Period occupied by proposer
Years
1i. Period in this type of business
Years
2. Fire Insurance Details
2a. Age of Building
Years
2b. Building has been rewired (if over 40 years old)
-
Yes
No
2c. Height of Building
Mtrs
2d. Approx. Area
sq. Meters
2e. Condition of Builiding
2f. Value of Contents
Fire Protection
2g. Single Sprinklers
-
Yes
No
2h. Dual Sprinklers
-
Yes
No
2i. Water Hydrant
-
Yes
No
2j. Extinguishers
-
Yes
No
2k. Vats
-
Deep Fryers
Thermo Controlled
Goods Protection
2l. Goods in open air
-
Yes
No
2m. Customers work in progress
-
Yes
No
3. Seasonal Stock
3a. Cover Amount
$
3b. Period Required
ie. December to March
3c. Extra cost of re-installment
$
4. Premises Details
Walls
4a. Block/Brick
-
Yes
No
4b. Timber
-
Yes
No
4c. Iron
-
Yes
No
4d. Fibro
-
Yes
No
4e. Other
4f. Roof
-
Iron
Tiles
4g. Other
4h. Floors
-
Concrete
Timber
4i. Other
5. Burglary Insurance Details
5a. Alarm
-- Choose --
Monitored
Local
No Alarm
5b. Connection
-- Choose --
Landline
Securitel
Dialler
Sensors
5c. Infra Red
-
Yes
No
5d. Glass Breakage Detector
-
Yes
No
Deadlocks
5e. All Doors
-
Yes
No
5f. Other
5g. Other
-- Choose --
Patrols
24 Security Guard
5h. Made a claim in the last 5 years
-
Yes
No
5i. Please Provide Details
5j. Have you ever had any insurance canceled or declined
-
Yes
No
5k. Have you ever been charged or convicted of any criminal offence or declared bankrupt?
-
Yes
No
6 . Insurance Amounts
Fire and Accidental Damage
6a. Building
$
6b. Stock
$
6c. Other Contents
$
6d. Removal of Debris
$
6e. Loss of rent
$
6f. Rewriting of records
$
Business Interruption
6g. Insurable gross profit
$
6h. Increased cost of working
$
6i. Claims preparation costs
$
6j. Accounts / Loss of debtors
$
Burglary
6k. Stock
$
6l. Tobacco / Cigarettes
$
6m. All other contents
$
6n. Theft without forceable entry
$
Money
6o. In Transit
$
6p. Business Hours
$
6q. Outside Business hours
$
6r. Seasonal Cover
$
ie.Weekends, Public Holidays, Christmas
6s. Locked Safe
$
6t. Residence
$
6u. Safes / Storerooms
$
Glass
6w. External
-
Yes
No
6x. Internal
-
Yes
No
6y. Illuminated and Neon Signs
$
Liability
6z. Public
$
7a. Products
$
General property
7b. General Property
$
Computers
7c. Hardware
$
7d. Data Media
$
7e. Inc. Costs
$
Machinery
7f. Unspecified
$
7g. Specified Items
$
7h. Boiler / Pressure Vessels require certification
-
Yes
No
7i. Food Spoilage
$
Goods in Transit
7j. Goods in Transit
$
Fidelity Insurance
7k. Number of Staff
$
7l. Amount of Cover
$
8. Contact Details
Please enter your contact details below so we can contact you regarding your quotation.
8a. Your Name*
8b. Daytime Phone Number*
8c. Your Email Address
8d. Your Fax Number
8e. Your Postal Address