MAAIS Contents Insurance Application

GYM CONTENTS INSURANCE QUOTE APPLICATION

GYM INSURANCE BROKERS division of Martial Arts Australia Insurance Services Pty Ltd ABN: 31 632 785 329 AFS Representative No: 001283262 of United Insurance Group Pty Ltd ABN 31 131 564 522 AFSL 327131
Please Note: There are number of elements in a business pack, some you may not need or can go with a lower limit. Fill in the form with what you feel is the appropriate information. We will call you to walk through each section and explain what it does and how you would claim against it.
Client History*

New ClientExisting ClientPrevious Client
Contact Name*

First NameLast Name
Insured Business Name - School / Legal Trading Entity:*
ABN / ACN
Interested Parties? Add them:
Date you require Insurance to start:*
Email*
example@example.com
Website
Mobile*
Phone
Address of premises to be Insured:*

Street Address

Street Address Line 2

SuburbState

Postal Code

Business Details:*

	Details
Estimated turnover for the next twelve months
Total number of staff – Full time
Total number of staff – Part time / Casual

Building and structure details*

	YES	NO
Is the building Heritage Listed?
Do you require Flood cover?
Are there Multiple Buildings on Site?
Is the premise connected to town water?
Is there an ATM on premises?
Does your premises contain a restaurant or bar?
Are there any deep fryers or any wok cooking?
Is there storage of waste material?
Is any part of the building used, or intended to be used, as a place of residence (whether by the insured or another person)?*

Approximate Year built*
Year (yyyy)
Year that the building was rewired*
Year (yyyy)
How much Expanded Polystyrene (EPS) does the premises contain (e.g. Foam insulation)?**
Number of Storeys*
Construction of Floor*
Construction of Walls*
Construction of Roof*
Fire Protection*

NoneSprinklersHeat DetectorsFire BlanketsFire ExtinguishersSmoke Detectors - MonitoredSmoke Detectors - Non MonitoredHose ReelsFire AlarmMonitored Base Alarm
Security*

NoneDeadlocks on DoorsBars on WindowsProtection of Display WindowsElectronic key pad/swipe card accessSecurity FencingBollards Infront of glazing/display windows/rollerLocks on all external windows without barsCCTV system installedExternal LightingLocal alarmWatchman patrolsMonitored base alarmRoller Shutters

Past Claims Questions: If Yes, please provide details:*

	YES	NO	Details
Has any insurance company refused to pay a claim by the insured? If yes, please provide details:
Has any claims made against you in the past 5 years?
Have you had an incident or accident which would be insured by the proposed insurance?
Have you been charged with or convicted of any criminal offence (excluding traffic offences)?
Have you ever, either alone or jointly with others, been declared bankrupt or subject to any form of insolvency administration (e.g. liquidation or receivership)?
Has any insurance being declined or cancelled, application/proposal rejected, renewal refused, claim rejected, or special conditions or excess imposed by any insurer?

Fire & Other Defined Events - Sum Insured (replacement / reinstatement value)

	Sum Insured Amount $
Building(s)
Contents and Stock In Trade
Flood cover

Business Interruption

	Amount $
Income - Annual Gross Profit OR BELOW
Weekly Income OR ABOVE / BELOW
Payroll OR ABOVE

Indemnity Period for Business Interruption
Burglary

Amount $

Contents and Stock Sum Insured

	Amount $
Contents and Stock Sum Insured

Money - (includes money in transit, on premises during and outside business hours, in safes or strong rooms and in personal custody)

	Amount $
Blanket cover Sum Insured

Glass - Covers Replacement*

	YES	NO
External Glass
Internal Glass

Machinery - General Property - Other

	Sum Insured $
Machinery Breakdown Sum Insured
Machinery Breakdown - Deterioration of Stock
Electronic Equipment - Blanket Cover Sum Insured OR
General Property - Laptop computers, video cameras, cameras, portable music players OR
General Property - All other items not otherwise excluded

Current Insurer*
If not currently insured type N/A
Current policy expiry date*
If not currently insured type N/A
DECLARATION
I/We the undersigned duly authorised person(s) declare that:
i. I am/we are authorised by each of the Proposers to sign this Proposal Form; and
ii. the above statements are correct, true and complete; and
iii. no information material to this Proposal Form has been withheld; and
iv. I/we have read the important facts which you have put before me/us and I/we understand the advice given in relation to the duty of disclosure; and
v. I/we have diligently made all necessary and detailed enquiries in order to comply with the duty of disclosure; and
vi. I/we understand that no insurance is in force until such time as the insurer has confirmed acceptance of the proposed insurance; and
vii. I/We undertake to inform the insurer of any material alteration to these facts occurring before completion of the contract of insurance; and
viii. I/we acknowledge that the Insurer relies on the information and representations in this Proposal Form and otherwise made by me/us in relation to this insurance.

This application form will be used to create a letter of offer for the nominated insurances you have selected. Upon your acceptance of this offer we will create the rest of documents (invoice / certificate of currency etc).

Send all correspondence to: Gym Insurance Brokers
division of Martial Arts Australia Insurance Services
Office: 6 / 12 Henderson Road, Knoxfield VICTORIA
Postal: P.O Box 2057 Blackburn South VICTORIA 3130
DISCUSS - P: 03 8201 9908 URGENT: 0451 331 958 (Text 24/7)
Please sign below to acknowledge you agree to the terms & conditions with the declaration above.*

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GYM CONTENTS INSURANCE QUOTE APPLICATION