Trades Insurance Needs Analysis
Broker Email Address - a copy of the form will be sent to this address
*
example@example.com
Client Reference
*
Date of Enquiry
-
Day
-
Month
Year
Date
Policy Due Date
-
Day
-
Month
Year
Date
Current Insurer
Who referred client?
Sales Team
Insured Details
Insured Name
Client Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: 0000000000.
Current Excess
Website
Situation of Risk
City, State, Postcode
Occupation
Full Description of Business Activities
General Property Section
Tools of Trade
Unspecified items (sum insured covering all items under $2000
Specified items over $2000
Rows
Description
$
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
Item 9
Liability Section
Public Liability
Products Liability
Goods in care custody & control
No. of Working Proprietors
No. of Employees
No. of Years in Business
Wages
No. of Subcontractors
Business Annual Turnover
Annual Subcontractor Payments
What tasks do your subcontractors undertake?
Other Relevant Notes
Trailer Details
Year
Make
Model
Value
Date of Purchase
-
Day
-
Month
Year
Date
Rego No.
Garaging Postcode
NCB
Rating
Type of Cover
Please Select
Fire/Theft & Third Party
Comprehensive
Third Party Only
Is the Vehicle Modified?
Please Select
Yes
No
Details of Modifications
Nonstandard Accessories
Rows
Description
Value $
Accessory #1
Accessory #2
Accessory #3
Accesspry #4
Details of All Drivers
Driver #1
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Year Obtained Licence
Percentage of Use
Driver #2
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Year Obtained Licence
Percentage of Use
Driver #3
Name
First Name
Last Name
Date of Birth
-
Day
-
Month
Year
Date
Gender
Please Select
Male
Female
Year Obtained Licence
Percentage of Use
Claims History
For last 5 years (include property damage, theft & fire claims)
Claim #1
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #1
Amount
Claim #2
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #2
Amount
Claim #3
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #3
Amount
Duty of Disclosure
Rows
Yes or No
Has the insured ever had insurance cancelled, declined, or special conditions imposed?
Yes
No
Has the Insured ever been charged or convicted of any criminal offence?
Yes
No
Has the insured ever been declared bankrupt or been placed in receivership?
Yes
No
Is the vehicle maintained in a roadworthy condition, in working order, free from mechanical defects and in an undamaged condition?
Yes
No
Does the vehicle operate interstate or more than 600 km from its base?
Yes
No
Has any person who will drive any of the vehicles had any convictions for driving under the influence of alcohol, drugs, or had a licence cancelled or suspended in the last 5 years?
Yes
No
Has the insured or any person who will normally drive the vehicle been convicted of any criminal offences during the last 5 years or have any charges currently pending?
Yes
No
If Yes, Provide Full Details
Broker Recommendations
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