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BUSINESS INSURANCE QUOTE FORM
Ten Seventy Pty Ltd t/a Reef Insurance Brokers is an Authorised Representative (AR # 1285127) of United Insurance Group (UIG) AFS Number 327131
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1
YOUR HAVE A DUTY OF DISCLOSURE OBLIGATION
*
This field is required.
Ok, so before we start we need to tell you some things... Yes, it's boring, but it’s important and we need to do this - it only takes a minute. YOUR DUTY OF DISCLOSURE Before you enter into an insurance contract, you have a duty to tell the insurer anything that you know, or could reasonably be expected to know, that may affect the insurer’s decision to insure you and on what terms. NOTE: You have this duty until the insurer agrees to insure you. You have the same duty before you renew, extend, vary, or reinstate an insurance contract. You do not need to tell the insurer anything that: • reduces the risk they insure you for; or • is common knowledge; or • the insurer knows, or should know; or • the insurer waives your duty to tell them about. IF YOU DO NOT TELL THE INSURER SOMETHING If you do not tell the insurer anything you are required to, they may cancel your contract, or reduce the amount they will pay you if you make a claim, or both. If your failure to tell the insurer is fraudulent, they may refuse to pay a claim and treat the contract as if it never existed. DUTY TO NOT MAKE A MISREPRESENTATION NOTE: if you are applying for a new consumer insurance contract, renewing a consumer insurance contract or varying an existing consumer insurance contract, which is an insurance policy obtained wholly or predominately in relation to personal, domestic or household insurance purposes, you must answer the specific questions asked by the insurer truthfully and accurately. In answering those questions, you must tell the insurer all information that’s known to you and that a reasonable person would be expected to provide in answer to the questions. APPLYING FOR A NEW CONSUMER INSURANCE CONTRACT OR VARYING AN EXISTING CONSUMER INSURANCE CONTRACT. • You have a duty under the Insurance Contracts Act 1984 (ICA) to take reasonable care not to make a misrepresentation to the insurer (your duty). • Your duty applies only in respect of a policy that is a consumer insurance contract, which is a term defined in the ICA. • Your duty applies before you enter into the policy, and also before you renew, extend, vary, or reinstate the policy. • Before you do any of these things, you may be required to answer questions and the insurer will use the answers you provide in deciding whether to insure you, and anyone else to be insured under the policy, and on what terms. To ensure you meet your duty, your answers to the questions must be truthful, accurate and complete. • If you fail to meet your duty, the insurer may be able to cancel your contract, or reduce the amount it will pay if you make a claim, or both. • If your failure is fraudulent, the insurer may be able to refuse to pay a claim and treat the contract as if it never existed.
I agree
I don't agree
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2
Policy Start Date:
*
This field is required.
We can't back date a start date, so if you are not sure - choose today. We can sort this out later.
-
Date
DD
MM
YYYY
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3
Insured is:
*
This field is required.
Individual / Sole Trader
Company
Partnership
Trust
Super Fund
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4
ABN:
ABN LOOK UP
if required
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5
Company Name:
This is the name that is registered with your ABN.
if required
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6
Trading Name:
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7
Please tell us your Name?
*
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First Name
Last Name
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8
What is your Business Address?
*
This field is required.
We need a street address please - your postal address is the next question. If you are a mobile business please tell us your home base address.
Street Address
Street Address
City
State
Post Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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9
Do you have a different Postal Address?
If you don't have a postal address - just leave this blank
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10
What is your Phone Number?
*
This field is required.
Area Code
Phone Number
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11
Email:
*
This field is required.
This is so we can email you your quote.
example@example.com
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12
Description of Business Activities:
*
This field is required.
Please tell us what you do?
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13
How many Directors or Owners are there in the Business (including you)
*
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14
You're doing great. How many employees do you have?
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This field is required.
This is the number paid employees you have including any Directors / Owners that also work in the business. e.g.: 2 full time and 3 part timers. Don't include your contractors just yet - that's the next question.
Head count - not FTE
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15
How many Sub Contractors do you have?
*
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Leave this blank if you don't have Sub-contractors.
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16
Duties of Sub-contractors
Please tell us what your sub-contractors do?
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17
What is your estimated Annual Turnover:
*
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This is your income before Wages, Expenses and Tax please
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18
Do you use Labour Hire staff in your Business?
*
This field is required.
Yes
No
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19
What are your average annual payments for Labour Hire?
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20
Duties performed by Labour Hire staff?
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21
What Limit do you want for your Public & Products Liability?
*
This field is required.
Note: Remember to check your Lease - you may have an obligation to have particular level of cover by your Landlord.
(5 Million - not recommended)
10 Million
20 Million
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22
Do you need to add an Interested Party?
*
This field is required.
E.g.: A Landlord that needs to be noted on your policy because of the Lease requirements?
Yes
No
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23
Great! Who are we noting on your policy under your Public Liability?
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24
Do you import any products from overseas that you re-sell in Australia?
*
This field is required.
Yes
No
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25
Ok so we need a bit of info on this one.
Please tell us what sort of product your import and the % of income derived from this? Please note the more info we have the better.
Product description, % of turnover for each product, country of origin
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26
Are the products subject to Australian Standards?
Yes
No
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27
What quality control standards and procedures are in place for importing products?
Huge
Large
Normal
Small
Ok
quote
Created with Sketch.
Ok
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28
Details of product recall procedures in place?
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29
We are nearly finished with all the questions. How much do you want to insure your Fitout and Contents for?
*
This field is required.
Don't include your stock - that's the next question
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30
How much do you want to insure your Stock for?
*
This field is required.
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31
Is any of your Stock - tobacco or alcohol related products
No
Yes
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32
Please tell us the cost of the Stock for the follow?
*
This field is required.
Alcohol Products
Tobacco Products
Sun Insured requested
Row 0, Column 0
Row 0, Column 1
Sun Insured requested
Alcohol Products
Row 0, Column 0
Tobacco Products
Row 0, Column 1
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33
Do you want Theft cover for Stock or Contents?
Yes for my Stock please
Yes for my Contents please
Yes for both please
No - I don't want this cover.
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34
How much Theft cover do you want for the following?
*
This field is required.
Stock
Contents
Alcholo / Tabacco
Sum Insured requested
Row 0, Column 0
Row 0, Column 1
Row 0, Column 2
Sum Insured requested
Stock
Row 0, Column 0
Contents
Row 0, Column 1
Alcholo / Tabacco
Row 0, Column 2
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35
Do you want Glass cover?
*
This field is required.
Don't forget to check your Lease, it may be a requirement of your Landlord that you have this cover. Note also that the Glass section of your policy also includes cover your Signs, Window Frames and Window Signwriting.
Yes please
No thanks, I don't need it.
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36
Do you want Money cover?
*
This field is required.
$2,000
$5,000
$10,000
No thanks - I don't need it.
Other
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37
In the past 5 years has any party lodged a Public or Products Liability claim against you?
*
This field is required.
Yes
No
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38
In the past 5 years have you made any claims for loss of Contents, Stock or Money?
*
This field is required.
Yes
No
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39
Claim history details
Please tell us what happened, the year and the value of the claim.
Year, details of claim / action, outcome, is the claim finalised or ongoing?
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40
Declaration: I declare the information provided by me in this form is true and correct.
YOUR FULL NAME
DATE
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41
Well done you're all finished. Before you hit that Submit button please tell us where you heard about us?
*
This field is required.
A Friend
Facebook
Local Google Search
A Reef IB Client referred me
Other
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