Trade Insurance Application

Trade Insurance Application

There are number of elements in a trade 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 then contact you asking for additional information applicable to your trade.
Contact Name*

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

Street Address

Street Address Line 2

SuburbState

Postal Code
Select Occupation*
Select Cover*

Public and Products LiabilityGeneral Property (Tools, Stock, Office Equipment, Glass)Tax AuditCyberIndividual Personal AccidentMobile PlantRegistered Mobile Plant Liability

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?

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.

Send all correspondence to: 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.*

Clear
About MAAIS Insurance Services

Martial Arts Australia Insurance Services ABN:31 632 785 329 Corporate Authorised Representative: 001283262 of United Insurance Group Pty Ltd ABN 31 131 564 522 Australian Financial Services License: AFSL 327131
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Trade Insurance Application

About MAAIS Insurance Services