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Business Insurance Quote Form
Fill the fields below accurately and we will contact you shortly.
Contact Person
First Name
Last Name
E-Mail
*
Email
Phone Number
*
Referred by
*
Who introduced you to us?
Company Name
Company Name
ABN
Business Description
Business Description
Any other business activities unrelated to above?
Estimated Annual turnover
Number of employees
Address
*
Street Address
Street Address Line 2
Suburb
State
Post Code
Situation Details
Fire Protection
*
Security Measures
*
Public Liability Cover
Limit of Liability
Please Select
$5mil
$10mil
$20mil
Property Damage Cover
Building Value
Current replacement value of the Building
Contents Value
Current replacement value of the business contents
Stock Value
Current replacement value of the business stock
Theft Cover
Contents Value
Stock Value
Tobacco
Money Cover
Money at premises during Business hours
Money at premises outside business hours
Money at private residence
Money in locked safe
Money in transit
Glass breakage cover
Do you require Glass Cover?
Yes
No
Glass Type
Internal only
External only
Both
Machinery Breakdown Cover
Blanket Machinery Cover
Please Select
$10,000
$15,000
$20,000
$30,000
$50,000
Limit of machinery breakdown in one event.
Deterioration of Stock
Cover for stock damage in case of machinery breakdown.
Electronic Equipment Breakdown
Blanket Equipment Cover
Please Select
$10,000
$15,000
$20,000
$30,000
$50,000
Limit of equipment breakdown in one event.
Business Interruption Cover
If required, fill below information
Annual gross profit
Indemnity period
Please Select
6 months
12 months
18 months
24 months
36 months
Tax Audit cover
Tax audit cover limit
Please Select
$10,000
$20,000
$50,000
Claims information
Have this business or any directors made any claims for the insurance covers applying for?
*
Yes
No
New business
Claims list
Underwriting Questions (in the last 5 years)
Had any business insurance/liability claims?
*
Yes
No
Suffered any loss or damage which would have been covered by your insurance policy?
*
Yes
No
Had any insurance declined or cancelled?
*
Yes
No
Been convicted of any criminal offence?
*
Yes
No
Been liable for any civil offence or pecuniary penalties?
*
Yes
No
Been declared bankrupt or involved in business which became insolvent or subject to any form of insolvency administration (e.g. liquidation, receivership or voluntary administration)?
*
Yes
No
Are you eligible for the NSW Small Business Stamp Duty Exemption i.e. you have a NSW based small business with turnover of less than $2 million per annum? Note: The exemption is effective for Public Liability and Professional Indemnity policies incepting on and after Jan 1 2018
*
Yes
No
Any other information that you want to provide?
Attach your current policy and/or claims history report.
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