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:*

  • 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 Package

  • Please select the sections you would like included in your package:*

  • If you wish to find out more about the covers available under a business package policy, please read our guide here.

  • Building Details

  • What is the floor made of*
  • What are the walls made of*

  • What is the roof made of*
  • How much Expanded Polystyrene (EPS) does the premises contain (e.g. Foam insulation)?*
  • Do you undertake wok cooking or deep frying?*
  • Does the capacity of single vat or twin vat deep fryers exceed 10 litres?*
  • Do all Deep Fryers have an automatic suppression unit and exhaust extraction system?*

  • Fire Protection

  • Fire protection provided:*

  • Security

  • Security Protection Provided:*

  • Other Details

  • Is there an ATM on the premises?*
  • Is your premises more than 50% vacant?**
  • Is the building heritage or national trust listed?*
  • Is there storage of waste material?*
  • Is waste removal conducted on a regular basis, under contract and kept away from the walls of the building?*
  • Do you store flammable goods?*
  • Do you store substances in accordance with Australian Standards and local/state government regulations?*
  • Are goods stored in approved cabinets/bunded storage facilities*

  • Property Damage Section

    Repair or replacement of property damaged.

  • Theft Cover

    Repair or replacement of property stolen
  • Is there full time on-site security after business hours / Retail or office in a building with after hour security (no external access)?*

  • Business Interruption

    Loss of trading profit following insured damage to property and additional costs andexpenses incurred during a claim

  • Machinery Breakdown

    Cover for costs associated with machinery breakdown
  • Do you undertake annual preventative maintenance of your machinery?*

  • Electronic Equipment Breakdown

    For repairing or replacing electronic equipment that breaks down

  • Goods in Transit

    For stock that is in transit on the road, in the air or by sea
  • Do you transport temperature controlled goods?*

  • Money Cover

    Loss of money

  • Glass Cover

    For replacing glass inside or outside your premises, including your shop front windows, mirrors or display cases

  • Employee Dishonesty

    Direct financial loss of the business caused by the dishonest or fraudulent conduct ofan employee which is first discovered during the period of insurance.
  • To your knowledge have any of your employees been charged with, or convicted of, a criminal offence relating to dishonesty, fraud, theft or embezzlement in the past 5 years?*
  • Are all accounting practices and functions of the business (including cash book entries, petty cash handling, balance in hand and any other records of monies received) subject to an independent check at least monthly?*
  • Is the accounting function of your business subject to an annual independent audit?*
  • Rows

  • Tax Audit

    To cover the costs of being audited by the ATO
  • Has the business and/or any director who will receive protection under this section had any previous Tax Audits?*
  • Has the Australian taxation office advised you that it intends to carry out an audit, or provided a general notification to your industry that it will be carrying out audits of your industry?*
  • Have you ever been investigated by the Australian tax office or Office of State Revenue and this investigation resulted in a fine, penalty, criminal charges or conviction?*

  • Public & Products Liability

    Your liability to pay compensation for personal injury and property damage as well asthe costs involved in defending a claim triggered by the policy
  • Do you engage contractors and/or subcontractors in your business?*
  • Do you ensure that contractors and/or subcontractors have their own liability and where necessary, Workers Compensation insurance?*
  • Do you engage labour hire or hired in labour in your business?*
  • Do you have any contracts to be designated?*
  • Do you, or do you intend to import goods?*
  • Does the business import any of the following:- prescription drugs or medical veterinary products- gases or air under pressure in containers- any aircraft, aircraft components or products- fireworks, ammunition, explosives or related products- motor vehicles, motor cycles, rolling stock, self-propelled vehicles or machinery or critical  components of motor vehicles or rolling stock, being structural components, driving  equipment, wheel hubs, brakes, steering equipment and tyres- tobacco products- blood or blood products- chemicals / cosmetics / toiletries / pesticides / insecticides- stockfeed- cured or fermented meat- baby food/furniture/safety equipment/clothing- scientific / surgical instruments/equipment- toys- mechanised sporting/gymnasium equipment- protective equipment*
  • Do you, or do you intend to use, store or handle hazardous substances?*
  • Do you discharge waste or hazardous material into the atmosphere, sewer or elsewhere?*
  • Do you hire equipment or hire out equipment and/or staff?*
  • Is there a Hire Agreement with a disclaimer or legal waiver in place that the hirer signs before hiring?*
  • Is all equipment checked and maintained after each hire?*
  • Does the business hire out any of the following:- medical or surgical equipment- watercraft- jumping castles- Elevated work platforms/scaffolding- chainsaws**
  • In the last 6 years or in the future, do you intend to undertake business or export to any of the following countries - Belarus, Burma (Myanmar), Cote d'Ivoire, Cuba, The Democratic Republic of the Congo, Iran, Iraq, Liberia, North Korea, Sudan, Syria or Zimbabwe?**
  • Do you, or do you intend to export goods?*
  • Do you intend to engage in any overseas activities in the next 12 months?*

  • General Property

  • Specified Items (anything with a single value greater than $2,500)

  • Add more specified items?

  • Management Liability

    Covers the costs of defending directors,managers and employees against any claims that are the result of their actions or decisions.

  • Given the complexity of cover, we have available a management 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

  • In the last 5 years have there been any claims made against the company or its directors or employees which may have been covered under this policy if it were in force?*
  • In the last 5 years has the company suffered any direct financial loss exceeding $5,000 as a result of fraud or dishonesty committed by a staff member?*
  • Has any director or officer of the company ever had proceedings (civil or criminal) instigated against them alleging misconduct or breaches of the law in their capacity as a director or officer of the company?*
  • Are any of the directors or employees aware of: (a) any facts which might give rise to a claim being made against the company or its directors or employees which may be covered under this policy section if it commences? (b) any facts which could cause a reasonable person to think that the company might suffer a direct financial loss as a result of fraud or dishonesty committed by a staff member?*
  • Does the company conduct business activities in the following countries - Belarus, Burma (Myanmar), Cote d'Ivoire, Cuba, The Democratic Republic of the Congo, Iran, Iraq, Liberia, North Korea, Sudan, Syria or Zimbabwe?*
  • Rows

  • 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*

  • 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

  • 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?

  • *

  • Commercial Motor

  • This form allows for the quotation of a single vehicle, if you have multiple vehicles to cover, please contact our office directly and we will be able to assist.

  • Is the vehicle unregistered or have any existing damage (excluding minor scratches, wear and tear or hail damage)*
  • Is the vehicle used for Driver Education, Racing or Sporting Event, Courier or Delivery Services*
  • Is the vehicle used as a Hire Car, Courtesy Car, Taxi or Removalist Vehicle*

  • Please note that we may not be able to provide quotations for you given your answer. 

    We ask that you provide a detailed explanation to the questions above to ensure the best possible outcome for you. 

  • Vehicle Details

  • Does the vehicle have any non-standard accessories that you would like insured?*
  • Does the vehicle have any modification that you would like insured?*

  • Cover Details

  • Cover*
  • Do you wish to include any of the following cover options:*

  • Driver Details

  • Are there any drivers under the age of 25?*
  • Has any driver of this vehicle had any criminal convictions in the past 5 years?*
  • Has any driver of this vehicle had any claims and/or licence suspensions in the past 5 years?*

  • Duty of Disclosure

    Have you or any partner(s) or director(s) of the business:
  • Ever had an insurance policy cancelled, declined or terms imposed?*
  • Ever been declared bankrupt?*
  • Ever been involved in a company or business which became insolvent or subject to any form of insolvency or voluntary administration (e.g. liquidation or receivership)?*
  • Been convicted of any criminal offence within the past 5 years (other than minor traffic convictions)?*
  • Been liable for any civil offence or pecuniary penalty (exceeding $5,000)?*
  • Have you, or any directors or officers entered into and SIGNED any contractual or Hold Harmless agreements that may affect our rights of recovery against other parties?* other than the following types of contracts; 1. A contract which releases any government, semi-government or municipal authority body from any liability, 2. contracts for storage of goods or merchandise; 3. lease agreements for the occupancy of any building or part of a building or lease or hire of property.**

  • Claims History

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

  • 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.

     

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  • 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

  • How did you hear about us?*

  • 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

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