Finance Brokers Office Package Proposal Form
Full Name of Company / Insured Entity:
*
ABN:
Contact Person's Name:
*
First Name
Last Name
Mobile Phone Number:
*
Format: (000) 000-0000.
Telephone Number:
-
Phone Number
Email:
*
example@example.com
Staff Numbers:
*
Rows
(a)
Principals / Finance Brokers:
(b) Credit Representatives / Contracted Consultants:
(c) Administration Staff
Risk Address:
*
Street / Postal Address
Address Line 2
City
State
Post Code
Year Built :
*
Example: 2011
Construction of walls:
*
Brick / Concrete
Iron / Steel
Other
Construction of Roof:
*
Tiles
Metal / Iron / Steel
Timber
Other
Fire Protection
*
Smoke Detectors
Fire Extinguishers
Automatic Fire Alarms
Fire Sprinklers
No Fire Protection
Other
Security:
*
No Security
Deadlocks on all doors
Locks / bars / grills on SOME windows
Locks / bars / grills on ALL windows
Local Alarm
Monitored Back to Base Alarm
CCTV Internal
CCTV External
Other
Sections of Cover: - Property
*
Rows
Yes
No
Property / Theft
Covers Loss / Damage to items whilst at the risk
address from Fire, theft & Specified Perils (As defined in Policy Wording)
Contents Sum Insured
*
Sections of Cover: - Business Interruption
*
Rows
Yes
No
Business Interruption
Cover the consequential loss of income as a result of an insured loss under Section One of the policy.
Additional Increased Costs of Working covers the additional costs incurred by you to reduce a loss of income &/or resuming to your normal business operations following a business interruption
loss.
Annual Gross Profit:
*
Additional Increased Cost of Working (minimum Sum Insured $25,000)
*
Sections of Cover: - Glass Cover
*
Rows
Yes
No
Glass
Covers for Accidental breakage of fixed glass
(as defined in PDS)?
Sections of Cover: - Mobile Equipment
*
Rows
Yes
No
Mobile Equipment
Covers Mobile Electronic Equipment for Fire & Perils, Accidental Damage & Theft Australia Wide.
Please provide list of Mobile Equipment WITH Sum insured for each item. NOTE any item over $2,500 will require Serial Numbers as well.
*
Sections of Cover: - Other
*
Rows
Yes
No
Any Other information or required Sections of Cover:
More Informatin and Cover/s required:
(20) Are you currently insured?
*
No
Yes
(If Yes, please provide FULL details):
*
YOUR PREVIOUS HISTORY - Have you either alone or inpartnership or jointly with any other party, or if a corporation, any of itsdirectors:
*
Rows
Yes
No
Had any claims in the last 5 years related to the Insurance now being requested?
Had any insurer decline any claim submitted?
Had any insurer decline any Proposal submitted?
Had any insurer cancel or refuse to renew a Policy?
Has any person or entity seeking cover under this policy ever been declared bankrupt?
Been convicted of or charged with any criminal offence?
If ‘Yes’ to any of the above, please provide FULL details:
*
Name of applicant:
*
First Name
Last Name
Digital Signature
*
Submit
Should be Empty: