Grazeland Insurance Application

Grazeland Vendor Insurance Application
This online form has been specifically designed for your site at Grazeland Melbourne, many of the answers have been pre-filled, if they are incorrect, please amend them.

If you have multiple sites, have queries on the form, or wish to discuss your broader insurance needs, please contact Peter Ligdopoulos directly on 0474203335 or peter@delphic.com.au
Please select the insurance policies you would like a quotation for:*

Business PackagePublic LiabilityGeneral PropertyManagement LiabilityCyber LiabilityProfessional IndemnityCommercial Motor

If you are uncertain as to what these insurance policies are, we have brochures available:

Business Package	Public Liability	Management Liability
Professional Indemnity	Cyber Liability	General Property

Also available are brochures on other policies that may be of interest:

Business Interruption	Contract Works	Corporate Travel
Event Insurance	Marine Transit	Trade Credit

We can also assist with any of your other general insurance needs. Please contact us for more information

General Business Information
Business Name*
Please include the legal entity
ABN*
Business Description*
Include the range of services and types of clients/customers you deal with
Number of directors/principals/partners*
Total number of full time employees*
If part time or casual, please calculate as 0.5 FTE
Business Address

Street Address

Street Address Line 2

CityState

Postcode
Estimated Income*

Cyber Liability
Given the complexity of cover, we have available a cyber liability proposal form to complete. It is available on our website www.delphicinsurance.com.au/proposals

We are able however to provide limited quotations on the answering of the below
Have you suffered a loss due to, or experienced any cyber incident that you have experienced in the last three years*

YesNo
Please provide more information below, including details of the financial impact and measures taken to prevent the incident from occurring again:*
Please attach any documentation to this application
Limit of Indemnity Required*

Professional Liability
Given the complexity of cover, we have available a professional indemnity proposal form to complete. It is available on our website www.delphicinsurance.com.au/proposals

We are able however to provide limited quotations on the answering of the below
Please confirm the professional activities provided and fees generated from each activity*
Are you are aware of any incident:
a) which may result in a claim under any of the insurance for which you are applying to purchase in this application form:
b) which resulted in legal action being made against any of the companies to be insured within the last 5 years:
c) or cease and desist orders been made against you;
d) which resulted in a partner or director being found guilty of any criminal, dishonest or fraudulent activity or been investigated by any regulatory body?
YesNo
Please describe the incident, including the monetary amount of the potential claim or the monetary amount of any claim paid or reserved for payment by you or by an insurer. Please include all relevant dates, including a description of the status of any current claim which has been made but has not been settled or otherwise resolved.
Please attached any supporting information
Limit of Indemnity Required*

Claims History
Have you had any claims in the last 3 years under any of the sections to be insured?*

YesNo
Please provide: 1 - a brief description of what happened, 2 - the date of loss and 3 - the settlement amount

Additional Information
Please attached any supporting documentation with your application, and any further information requested on thie application form.

We also welcome you to attach your current insurance policies for review, this way we can identify potential coverage issues between the policies so you can make an informed decision.
Browse Files

Cancelof

Contact Information and Confirmation
SIGNING THIS PROPOSAL FORM DOES NOT BIND THE PROPOSER OR THE INSURER TO COMPLETE THIS INSURANCE

The undersigned declares that the statement and particulars in this proposal form are true and that no material facts have been misstated or suppressed after enquiry. The undersigned agree that should any of the information given by us alter between the date of this proposal and the inception date of the insurance to which this proposal relates, the undersigned will give immediate notice thereof. The undersigned agrees that the Underwriters may use and disclose our personal information in accordance with the “Privacy Statement” at the beginning of this Proposal. The undersigned agrees that this proposal, together with any other information supplied by us shall form the basis of any contract of insurance effected thereon.

TO BE SIGNED BY THE INSURED FOR WHOM THIS INSURANCE IS INTENDED FOR
Full Name*
Email*
example@example.com
Phone Number*
Message
How did you hear about us?*

GoogleReferred by current clientFamily / FriendFacebookInstagramOther
Please sign*

Clear
IT IS IMPORTANT THE UNDERSIGNED OF THE DECLARATION ABOVE IS FULLY AWARE OF THE SCOPE OF THIS INSURANCE SO THAT THESE QUESTIONS CAN BE ANSWERED CORRECTLY. IF IN DOUBT PLEASE CONTACT THE BROKER OR AGENT, SINCE NON-DISCLOSURE MAY AFFECT AN ASSURED’S RIGHT OF RECOVERY UNDER THE POLICY
Please verify that you are human*
Should be Empty:

	NSW	VIC	QLD	ACT	SA	WA	NT	TAS	O/S
Number of executives and employees responsible for finances, cash and/or stock
Number of employees primarily engaged outdoors handling cash, negotiable instruments, stock, accounts or delivering goods
Number of all other employees not having responsibility for cash, negotiable instruments, stock and/or accounts

Grazeland Vendor Insurance Application