Restaurants
Cafes and
Bakeries
Application form filled in by
*
Please Select
Applicant
Insurance Web Representative
Other
Office staff member:
*
Please Select
Sonya Wilmen
Jason Matthey
Travis Rock
Ben Duka
Jedd Croxton
Darryn Somerville
Other
How did you hear about us?
*
Please Select
Searching online for insurance providers
Web Advertisement
Word of mouth referral
Yellow Pages online
Email marketing
Innovatus Group"
Total Advice Partners
ACBC
Business Infusion Group
Darryn Somerville
Other
Information about completing this form on-line
Please show me more about the on-line process before I begin
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By completing and submitting this application form you are consenting to have quotations for this class of insurance obtained from various insurance companies that provide this product and who have distribution agreements with United Insurance Group Pty Ltd and Insurance Web Pty Ltd.
Quotations are provided to you obligation free. A completed form does
NOT BIND
the applicant to complete the insurance but does form part of any insurance contract that should develop from the information provided in this document. Persons completing this application must have the right authority to do so or must have the application reviewed and signed off by those persons with the authority to enter into contractual agreements for and on behalf of the entity named in this application.
This quotation facility enables you to lodge a quote request direct to the Insurance Web Customer Service Team with the right information for quick and accurate assessment and thereby provides a superior service in dealing with insurance companies and you as our valued customer.
Simply complete the on-line form and the information will be sent to the appropriate Customer Service team. Following receipt of your request, an email response will be forwarded to you within 2-4 business days.
We are committed to protecting your privacy and confidentiality in accordance with the Privacy Act 1988 (Cth)
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Important - please read before completing this form
Privacy
We are committed to protecting your privacy and confidentiality in accordance with the Privacy Act 1988 (Cth) and it is one our prime concerns that any personal or sensitive information you provide to us is not used for any other purpose than that intended and expected by you. This Privacy Policy overview below, describes our current policies and practices in relation to the handling and use of personal information. You may also see our Privacy policy in our Financial Services Guide (FSG).
What information do we collect and how do we use it?
We will collect personal information for primary purposes, which are relevant to providing and administrating our products and services.
We collect the information needed to enable us to provide advice on and arrange financial services. We will usually provide some or all of this information to our product suppliers. Some of these suppliers may be located outside Australia.
To enable us to assess any claims made under an insurance policy we and our representatives (including loss adjusters, investigators, medical advisors and lawyers) collect information about the claim, some of which may be personal information. We may collect the information from you or from third parties. We provide this information to the insurer and those appointed to assist you in making a claim. We may use personal information internally to help us improve our services and help resolve any problems.
What if you don't provide some information to us?
We can only apply for and arrange financial service products if we have all relevant information. The insurance laws also require you to provide us with all the information we need in order to be able to decide whether to insure and on what terms.
How do we hold and protect your information?
We hold the information we collect from you in our computer system and in our hard copy files. We ensure that your information is safe by following the usual security procedures expected by our clients.
Will we disclose the information we collect to anyone?
We may disclose information to:
• Insurers, underwriters, underwriting agencies, wholesale brokers and reinsurers
(for the purpose of seeking recovery from them or to assist them to assess insurance risks);
• Premium Funding companies for the purposes of gaining quotations on and arranging funding of your
insurance premiums.
• An investigator, assessor, State or Federal Health Authorities, lawyers, accountants, medical
practitioners, hospitals or other professional advisors (for the purposes of investigating or
assessing your claim);
•
A lawyer or recovery agent (for the purpose of defending an action by a third party against
you or for the purpose of recovery costs including your excess);
• Contractors who supply services to us, e.g. to handle mailings on our behalf.
• An immediate family member;
• Other companies in the event of a corporate sale, merger, reorganisation, dissolution or similar event
However, we will do our best to ensure that they protect the information in the same way that we do. We may provide this information to others if we are required to do so by law or under some unusual other circumstances which the Privacy Act permits. We do not sell, trade, or rent personal information to others.
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Duty of Disclosure
Before you enter into this contract of insurance with an insurer, the Insurance Contracts Act 1984 requires you to tell us and the insurer everything of which you are aware, which you know, or which a reasonable person in the circumstances could be expected to know is relevant to our decision, whether and on what terms your application for insurance is acceptable and to calculate the premium required for your policy.
The Act imposes a different duty the first time you enter into the policy with us, from the duty that applies when you renew, vary, extend, reinstate or replace your policy. We set these duties out below.
Your duty of disclosure applies when you enter into this policy with us for the first time.
You will be asked various questions when you first apply for this policy. When you answer these questions, you must:
• give us honest and complete answers;
• tell us everything you know;
• tell us everything that a reasonable person in the circumstances could be expected to tell us.
Who needs to tell us
It is important that you understand, that you are disclosing to us and answering our questions for both you and anyone else who you want to be covered by the policy.
Non-disclosure or Misrepresentation
If you do not tell us
If you do not answer our questions honestly or do not properly disclose to us, the insurer may reduce or refuse to pay a claim or may cancel the policy. If you act fraudulently in answering our questions or not disclosing to us, the insurer in turn, may refuse to pay a claim or treat the policy as never having existed. This would mean that you were never insured.
Your duty of Disclosure applies when you renew, vary, extend, reinstate or replace your policy
When you renew, vary, extend or reinstate your policy, your duty is to tell us before the renewal, variation, extension or reinstatement, every matter known to you, which:
• you know; or
• a reasonable person in the circumstances could be expected to know;
• is relevant to an insurance providers decision whether to insure you and, if so, on what terms.
What you do not need to tell us when you renew, vary, extend or reinstate your policy
You do not need to tell us about any matter:
• that diminishes the insurance providers risk;
• that is of common knowledge;
• that we know or should know as an insurer; or
* that we tell you we do not need to know.
Non-disclosure and Misrepresentation
If you make a misrepresentation to us, or if you do not comply with your duty of disclosure and we issue your policy with terms and conditions that are different to the terms and conditions that would have been issued had there not been any misrepresentation, or your duty of disclosure had been complied with, then:
• the insurer may reduce the cover provided, so that we are placed in the same position as they
would have been in, had there not been any misrepresentation and your duty of disclosure had
been complied with; and
• the insurer may also cancel your policy; or
• the insurer may treat your policy as if it never existed if the misrepresentation or your
non-compliance with your duty of disclosure was fraudulent.
Cover Variation - Management Liability Cover Section
Please note the Management Liability Cover Section is issued on a
CLAIMS MADE
basis. This means that this policy responds to:
• claims made against you during the policy period and notified us during that policy period,
providing that you were not aware at any time prior to the policy inception of circumstances
which would have put a reasonable person in your position on notice that a claim may be made
against you; and
• pursuant to Section 40 sub-section 3 of the Insurance Contract Act 1984, the policy will also apply
to events of which you first became aware during the policy period which could give rise to a future
claim, provided that you notify us during that policy period of the circumstances of such events.
Policy Details
For full details of cover, please refer to the Product Disclosure Statement and/or Policy wording which sets out the terms and conditions of cover offered. This is available on request and will be sent out with your quotation once prepared.
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Proposed Policy Start Date
Enter the proposed start date for insurance cover or the expiry date of the existing policy
*
-
Day
-
Month
Year
Date Picker Icon
Your Contact Information
First Name
*
Last Name
*
Phone number
Enter your E-mail address
Mobile number
*
Enter the name of the current insurer
*
Please Select
No previous insurance (New Venture)
No previous insurance (Existing Business operational more than 3 months)
AAMI
ACE
Allianz
AMP
Ansvar
Calliden
CGU
Chartis
Chubb
GIO
Lumley
Miramar
NRMA
QBE
Suncorp
Vero
Zurich
Unknown?
Other
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Situation Address of the principal place of operations
Address Line 1
*
Address Line 2
Enter Suburb or City
*
Select State
*
Please Select
QLD
NSW
VIC
TAS
SA
WA
NT
ACT
Enter Postcode
*
Is the mailing address different from the principal place of operations?
*
Yes
No
Please enter your
mailing address
details
Mail Address Line One
*
Mail Address Line Two
Enter Suburb or mail centre location
*
Select Mail State
*
Please Select
QLD
NSW
VIC
TAS
SA
WA
NT
ACT
Enter Mail Postcode
*
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Details of those proposed to be insured
Please select the type of Entity to be insured
*
Please Select
Australian Private Company (Pty Ltd)
Australian Public Company (Ltd)
Australian Private Company (Pty Ltd) with a Trading Name
Australian Private Company (Ltd) with a Trading Name
Individual/Sole Trader
Individual/Sole Trader with a Trading name
Other Entity Type
Enter the Name of the Business
*
Enter your First Name
*
Surname
*
Enter the Trading Name
*
Select the Business activities at this location
*
Bakery
Cafe/Coffee Shop
Restaurant
Restaurant/Night Club/Bar
Takeaway Foods
Website address (if you have one)
ABN (Australian Business Number)
Registered for GST?
Yes
No
Approx date which the Proposer Commenced Business Operations
-
Day
-
Month
Year
Date Picker Icon
Does the business have a Stamp Duty Exemption?
Yes
No
Upload an Attachment
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Duty of Disclosure
Have you or any partner(s) or director(s) of the business:
1. Ever had an insurance policy cancelled, declined or terms imposed?
*
Yes
No
Date
-
Day
-
Month
Year
Date Picker Icon
Brief Description
2. Ever been declared bankrupt?
*
Yes
No
Date
-
Day
-
Month
Year
Date Picker Icon
Brief Description
3. 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)?
*
Yes
No
Date
-
Day
-
Month
Year
Date Picker Icon
Brief Description
4. Been convicted of any criminal offence within the past 5 years (other than minor traffic convictions)?
*
Yes
No
Date
-
Day
-
Month
Year
Date Picker Icon
Brief Description
5. Been liable for any civil offence or pecuniary penalty (exceeding $5,000)?
*
Yes
No
Date
-
Day
-
Month
Year
Date Picker Icon
Brief Description
6. Any other matters you should disclose?
*
Yes
No
Date
-
Day
-
Month
Year
Date Picker Icon
Brief Description
Please provide more details to all Yes responses above
*
Upload an Attachment
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Claims Experience
Any claims in the last 5 years under the sections to be insured?
*
Yes
No
Number of claims in the past 5 years
*
Please Select
None
1 claim
2 claims
3 claims
more than 3 claims
Claim #1
Cover section claimed under
*
Please Select
Business Property
Business Interruption
Theft
Money
Machinery Breakdown
Electronic Equipment
Public/Product Liability
Glass
General Property
Taxation Audit
Management Liability
Goods in Transit
Other
Date of Loss
*
-
Day
-
Month
Year
Date Picker Icon
Amount Incurred
*
Please provide details
*
Preventative/Corrective action details
*
Upload an Attachment
Claim #2
Cover section claimed under
Please Select
Business Property
Business Interruption
Theft
Money
Machinery Breakdown
Electronic Equipment
Public/Product Liability
Glass
General Property
Taxation Audit
Management Liability
Goods in Transit
Other
Date of Loss
-
Day
-
Month
Year
Date Picker Icon
Amount Incurred
Please provide details
Preventative/Corrective action details
Upload an Attachment
Claim #3
Cover section claimed under
Please Select
Business Property
Business Interruption
Theft
Money
Machinery Breakdown
Electronic Equipment
Public/Product Liability
Glass
General Property
Taxation Audit
Management Liability
Goods in Transit
Other
Date of Loss
-
Day
-
Month
Year
Date Picker Icon
Amount Incurred
Please provide details
Preventative/Corrective action details
Upload an Attachment
For more than 3 losses in 5 years, please provide details of each claim on a separate form listing:
1. Cover section claimed under
2. Date of Loss
3. Amount Incurred
4. Details of the incident
5. Preventative/Corrective action taken
6. Claims History Report on Insurance Company Letterhead
for each of the past three years
Upload an Attachment
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Cover Sections required for this situation
0 Please select the cover sections you require for this situation
*
Business Property
Business Interruption
Theft
Money
Machinery Breakdown
Electronic Equipment
Public Liability
Glass
General Property
Goods in Transit
Tax Audit
Management Liability
Is there a Lease Agreement in place with a property owner for this location?
*
Yes
No
NOTE
:
Most lease agreements require the tenant to carry
liability insurance
and may also enforce a mandatory requirement for the tenant to carry
external glass cover
and
machinery breakdown
for air-conditioning and/or exhaust fans attaching to the building.
Description of the Business
Please describe the activities of the business in more detail
*
Number of seats available for "Dining In" patrons
*
Service of Alcohol
*
Please Select
The Premises is not licensed
The Premises has a limited BYO License
The Premises has a full liquor license
The Premises is a Restaurant/Bar/Night Club
Other
Estimated turnover/gross income for the next twelve months:
*
Total number of staff - Full time
*
Total number of staff - Part time/Casual
*
Is this premises the only situation address to be insured?
*
Yes
No
Does the business have operations, with a permanent office set up in more than one state within Australia or income derived from Overseas?
*
Yes
No
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Demographic of Business Operations per State in Australia
Number of locations
Please Select
2
3
4
5
6
Other
Please list other property locations
Please check those that apply, including the principal base state of operations
QLD
NSW
ACT
VIC
TAS
SA
WA
NT
Overseas
As indicated there are multiple locations from which the business trades, please provide a percentage split of income per state and/or any income derived from overseas
QLD %
NSW %
ACT %
VIC %
TAS %
SA %
WA %
NT %
Overseas %
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Building & Construction Details
Approx Year Built (yyyy)
*
Number of Stories
*
Please Select
1 - ground floor only
2 - ground and upper level
3 - ground and 2 floors
4 - ground and 3 floors
More than 4 levels
Are there Multiple Buildings on this site
*
No
Yes
More information about multiple buildings
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Building Construction Material Details
Floors
*
Please Select
Concrete
Iron / Steel
Brick
Timber
Other/Mixed (Non Combustible)
Other/Mixed (Full/Partially Combustible)
Tile
Other
2nd and upper Floor construction
*
Please Select
Concrete
Iron / Steel
Brick
Timber
Other/Mixed (Non Combustible)
Other/Mixed (Full/Partially Combustible)
Tile
Other
Walls
*
Please Select
Concrete / Stone
Concrete Tilt Slab
Iron / Steel / Aluminium on Steel Frame
Iron / Steel / Aluminium on Timber Frame
Brick
Masonry
Expanded Polystyrene (EPS)
Timber / Wood
Mixed < 75% Brick/Concrete/Iron on Steel
Mixed > 75% Brick/Concrete/Iron on Steel
Glass
Metal
Polystyrene
Other
Roof
*
Please Select
Concrete
Masonry
Tile / Slate
Asbestos
Fibro
Iron/Steel/Aluminium on Steel
Iron/Steel/Aluminium on Timber/Wood
Expanded Polystyrene (EPS)
Wood
Polystyrene
Glass
Other Mixed (Non Combustible)
Other/Mixed (Full/Partial Combustible)
How much Expanded Polystyrene (EPS) does the premises contain (e.g. Foam insulated walls, Cold Rooms or Cold Storage walls are likely to contain this for example)?
*
Please Select
0 %
1 % - 14%
15% - 19%
20% - 29%
> 30%
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Fire Protection
Fire Protection Provided
*
None
Fire Extinguishers
Fire Blankets
Hose Reels
Sprinklers
Smoke Detectors - Monitored
Smoke Detectors - Non Monitored
Heat Detectors - Monitored
Fire Alarm - local audio only
Monitored Fire Alarm to Fire Station
Other
Sprinkler Type:
100% Coverage
Please Select
Yes
No
Water Supply
Please Select
Single
Dual
Conforms to Australian Standards
Please Select
Yes
No
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Physical Security & Alarm Type
Security Protection Provided
*
None
Bars on Windows
Deadlocks on doors
Protection of Display Windows
Electronic key pad/swipe card access
Security fencing
Locks on all external windows without bars
CCTV system installed
Bollards in front of glazing/display windows/roller shutters
External Lighting
Local burglar alarm
Roller Shutters
Watchman patrols
Monitored base alarm
Other
Please select the monitored base alarm type
*
Please Select
Class 2 e.g. Digital Dialler
Class 2 e.g. Digital Dialler + GSM Cellular phone back-up polled daily
Class 3 e.g. Multi-path GPRS polled < 120 sec
Class 4 + 5 e.g. Direct Line or Multi-path Ethernet / GPRS polled < 60 sec
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Other Details
Is there an ATM on the premises?
*
Yes
No
Where are the premises located?
*
Please Select
Main or Suburban Street
Wholly within a shopping centre (No external openings to outside centre)
Within a shopping centre (With external openings)
Within an Industrial Complex
Within an Office Block (incl Ground or 1st Floor)
Within an Office Block (2nd floor or above)
Outside Metropolitan, regional or town boundaries
Other
Is premises connected to town water?
*
Yes
No
Type of Fire Brigade
Please Select
Professional Manned 24 hours
Professional Manned part time
Own on site staff fire brigade Manned 24 hours
Own on site staff fire brigage Manned part time
Rural or country volunteer brigade
Other
Store Flammable Goods?
*
Yes
No
If Yes - how many litres?
*
Are storage of flammable substances in accordance with Australian Standards and local/state government regulations?
Yes
No
Are goods stored in approved cabinets/bunded storage facilities?
Yes
No
Please describe flammable substances storage:
Seasonal Increases
Seasonal Increase periods will apply to Property, Theft, Money and Machinery Deterioration of Stock Sections only
Do you wish to change the standard Seasonal Increase Periods?
*
Yes
No
First Period: From
-
Day
-
Month
Year
Date Picker Icon
First Period: To
-
Day
-
Month
Year
Date Picker Icon
Second Period: From
-
Day
-
Month
Year
Date Picker Icon
Second Period: To
-
Day
-
Month
Year
Date Picker Icon
Interested Parties
Do you wish to note any interested parties? i.e. Financial and/or Lessor names
*
Yes
No
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Interested Parties
Nature of Interest
Please Select
Property Lease
1st Mortgagee
2nd Mortgagee
3rd Mortgagee
Local Government Authority
Hire Purchase
Premium Funder
Principal
Other
Full Name of Interested Party
Address Line 1
Address Line 2
Suburb
State
Please Select
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
Postcode
Add another interested party
Yes
No
Nature of Interest
Please Select
Property Lease
1st Mortgagee
2nd Mortgagee
3rd Mortgagee
Local Government Authority
Hire Purchase
Premium Funder
Principal
Other
Details of other Interested Parties:
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Business Property Cover Section
This Cover Section is also known as
Fire and Perils
.
Cover provided under this section includes damage to assets such as building/s, contents, stock, plant & machinery, business equipment and the like, caused by fire, storm, water & other nominated perils.
Flood cover would also come under this cover section but must be specifically included. Some insurance companies will offer flood and others will refuse to provide it as an optional extension.
Please select "Yes" to proceed with the Business Property section...
*
Yes
No
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Business Property Cover Section
Business Property Information
Does the premises contain a multiple occupancy of tenants?
*
Yes
No
Is the premises more than 50% vacant?
*
Yes
No
Is the building heritage or national trust listed?
*
Yes
No
Is there storage of waste material?
*
Yes
No
Is waste removal conducted on a regular basis, under contract and kept away from the walls of the building?
*
Yes
No
If No, please provide details
*
If you are a Bakery, does your premises contain a restaurant/cafe or bar?
*
Yes
No
Are there any deep fryers or any wok cooking?
*
Yes
No
What is the total number of litres of oil used for deep frying?
*
Does the capacity of a single vat or twin vat deep fryers exceed 10 litres?
*
Yes
No
Do you have an automatic suppression unit on your Deep Fryers and exhaust extraction system?
*
Yes
No
Are deep fryers thermostatically controlled and fitted with an automatic over-temperature cut out device?
*
Yes
No
Is there a professional cleaning contract to clean exhaust ducts at least every 6 months?
*
Yes
No
Are the filters cleaned every 6 months at a minimum?
*
Yes
No
Describe Cleaning & Maintenance Procedure if no professionals cleaning contracts exist
*
Are the filters cleaned under contract at least every 2 weeks?
*
Yes
No
Are the wet chemical and/or dry chemical B(E) fire extinguishers and fire blankets in place and serviced every 6 months?
Yes
No
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Property Amounts to be Insured
Include Flood coverage?
*
Please Select
Yes, please only provide property insurance with Flood Cover
No, not required
Building(s) amount to be insured
Type of cover
Please Select
Replacement
Indemnity
Type of cover
Please Select
Replacement
Indemnity
Contents amount to be insured
Stock
Add Specific Items to be listed
Yes
No
Specified Business Property #1
Category #1
Please Select
Antique
Work of Art
Architects and Surveyors Fees
Container Contents
Floating Stock
Floating Stock and/or Contents
Rent
Additional temporary protection
Other
Sum Insured #1
Add another business property specified item
Add
Specified Business Property #2
Category #2
Please Select
Antique
Work of Art
Architects and Surveyors Fees
Container Contents
Floating Stock
Floating Stock and/or Contents
Rent
Additional temporary protection
Other
Sum Insured #2
Add another business property specified item
Add
Specified Business Property #3
Category #3
Please Select
Antique
Work of Art
Architects and Surveyors Fees
Container Contents
Floating Stock
Floating Stock and/or Contents
Rent
Additional temporary protection
Other
Sum Insured #3
Add another business property specified item
Add
Description of more items - please upload listing
Attachment
Deductible or Excess
Select your excess option for the Property Cover Section
*
Please Select
$250 - default value
$100
$500
$750
$1,000
$2,000
$5,000
$7,500
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Business Interruption Cover Section
This section of cover can also be referred to as Loss of Profits, Consequential Loss of Profits or Cash Flow Protection
The purpose of this cover is to provide protection for the loss of trading income & increased expenses due to damage to fixed assets or prevention of access.
Increased expenses may include the costs of moving premises, advertising costs, additional costs of hiring specialised contractors to reinstall computer equipment at a new location, to give some examples.
Note
: The Property or Fire and Perils Section must include
Flood
cover as an optional extension of cover in order for a business to be granted protection under this cover section for any losses caused directly or indirectly by
Flood
.
Apart from the usual case of a business not being able to trade due to direct flood damage, this can include indirect damage for things like 'Prevention of Access' to the business and/or losses at major suppliers premises causing interruption at your business premises as a consequence.
Please select "Yes" to proceed with the Business Interruption section...
*
Yes
No
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Business Interruption Cover Section
Type of Cover
*
Please Select
Insurable Gross Profit
Annual Revenue basis
Weekly Revenue basis
Additional Increased Costs of Working Only
Insurable Gross Profit sum insured:
*
Indemnity Period (months)
*
Please Select
6
12
18
24
36
Annual Revenue sum insured:
*
Indemnity Period (months)
*
Please Select
6
12
18
24
36
Weekly Revenue sum insured:
*
Additional Increase in cost of working
Indemnity Period (weeks)
*
Please Select
26
52
Loss of Rent Receivable
Additional Benefits of Cover
more to add
Accounts Receivable
Claims Preparation Costs
Documents
Please Select
Default Wording Coverage
Other Amount
Specified Amount
Optional Benefit
Goodwill
Add any Attachments
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Burglary/Theft Section
Burglary following a break and enter.
Some insurance companies will also include Theft from an open yard to a specified limit.
Please select "Yes" to proceed with the Burglary/Theft cover section...
*
Yes
No
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Burglary/Theft Section
Cover Type
Please Select
Contents - excluding stock
Contents - including stock
Sum Insured
*
Stock in Trade
Sum Insured
*
Cigarettes / Tobacco in Stock
Sum Insured
Alcohol in Stock
Sum Insured
Do you wish to add any particular specified items?
*
Please Select
Yes
No
Specified Item
#1
Category
*
Please Select
Floating stock and/or contents
Additional loss of keys
Antique
Work of Art
Customers Goods
Customers Vehicles
Trees/Shrubs/Plants
Other
Sum Insured
*
Description
Add another
Add
Specified Item
#2
Category
*
Please Select
Floating stock and/or contents
Additional loss of keys
Antique
Work of Art
Customers Goods
Customers Vehicles
Trees/Shrubs/Plants
Other
Sum Insured
*
Description
Add another
Add
Specified Item
#3
Category
*
Please Select
Floating stock and/or contents
Additional loss of keys
Antique
Work of Art
Customers Goods
Customers Vehicles
Trees/Shrubs/Plants
Other
Sum Insured
*
Description
Add another
Add
Specified Item
#4
Category
*
Please Select
Floating stock and/or contents
Additional loss of keys
Antique
Work of Art
Customers Goods
Customers Vehicles
Trees/Shrubs/Plants
Other
Sum Insured
*
Description
Additional Benefits
Damage to Rented Premises
Please Select
Default Policy Wording Cover
Other Amount
Sum Insured
*
Theft (limited) Without Forcible and Violent Entry
Please Select
Default Policy Wording Cover
Other Amount
Sum Insured
*
Theft in Open Air
Please Select
Wording Cover
Other Amount
Sum Insured
*
Theft without Forcible and Violent Entry
Please Select
Wording Cover
Other Amount
Sum Insured
*
Deductible or Excess amount for this section (Theft):
*
Please Select
$250 default value
$500
$750
$1,000
$2,000
$5,000
$7,500
$100
Do you wish to add any notes?
*
Yes
No
Notes:
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Money Cover Section
Loss or damage to cash, cheques and negotiable instruments.
Please select "Yes" to proceed with the Money Cover section...
*
Yes
No
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Money Cover Section
Type of Cover
*
Please Select
Blanket Cover
Split up as below
Sum Insured
*
Money in the Building - during business hours
Money in the Building - outside business hours is limited to $1,000 if blanket cover is selected
Money in the Building - outside business hours
Money in Transit or at Home Premises
Money in the Building - locked safe or strongroom
Deductible or Excess amount for this section (Money):
Please Select
$250 default value
$500
$750
$1,000
$2,000
$100
Do you wish to add any notes?
Yes
No
Notes:
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Machinery Breakdown Cover Section
Repair costs incurred following breakdown of plant & equipment
Air Conditioning
Refrigeration Equipment
and others
Optional extension of cover:
Deterioration of Stock resulting from the breakdown of refrigeration
Please select "Yes" to proceed with the Machinery Breakdown Cover section...
*
Yes
No
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Machinery Breakdown Cover Section
Plant and Machinery - Limit any one loss
*
Please Select
$10,000
$15,000
$20,000
$25,000
$30,000
$40,000
$50,000
Other Sum Insured Amount
Cover to include Air Conditioners
*
Yes
No
Air Conditioning Equipment
1)
Air Conditioners - Window/Wall Type Up to 5 HP (3.7kw)
Number of Window/Wall Type Up to 5 HP (3.7kw)
2)
Air Conditioners - Window/Wall Type Over 5 HP (3.7kw)
Number of Window/Wall Type Over 5 HP (3.7kw)
3)
Air Conditioners - Split System - Up to 5 HP (3.7kw)
Number of Split Systems - Up to 5 HP (3.7kw)
4)
Air Conditioners - Split System - Over 5 HP (3.7kw)
Number of Split Systems - Over 5 HP (3.7kw)
5)
Air Conditioners - Ducted System - Over 5 HP (3.7kw)
Number of Ducted Systems - Over 5 HP (3.7kw)
6)
Evaporative Coolers - Less than 3 HP (2.24kw)
Number of Evaporative Coolers
7)
Other information
Description and number of OTHER types of Air Conditioning
Refrigeration
Equipment
1)
Bottle/Display Cabinets
Number of Bottle/Display Cabinets
*
2)
Cold/Freezer Rooms Less than 3 HP
Number of Cold/Freezer Rooms Less than 3 HP (2.24kw)
*
3)
Cold/Freezer Rooms Over 3 HP
Number of Deep Freezers - Up to 2m long
*
4)
Deep Freezers - Up to 2m long
Number of Cold/Freezer Rooms Over 3 HP (2.24kw)
*
5)
Deep Freezers - Over 2m long
Number of Deep Freezers - Over 2m long
*
6)
Domestic Fridges
Number of Domestic Fridges
*
7)
Domestic Freezers
Number of Domestic Freezers
*
8)
Evaporative Coolers for Refrigeration
Number of Evaporative Coolers
*
9)
Ice Maker/Storage Bin
Number of Ice Maker/Storage Bin
*
10)
Refrigeration up to 5 HP (3.7kw)
Number of Refrigeration up to 5 HP (3.7kw)
*
11)
Other Refrigeration Equipment or items over 5 HP (3.7kw)
Description and Number of OTHER items and or items over 5 HP (3.7kw)
*
General Item Descriptions
1)
Coffee Machines
Number of Coffee Machines
*
2)
Cash Registers
Number of Cash Registers
*
3)
Electronic Scales
Number of Electronic Scales
*
4)
Bar Coding Scanners
Number of Bar Coding Scanners
*
5)
Electric Motors - Less than 2 HP (< 1.5kw)
Number of Electric Motors - Less than 2 HP (< 1.5kw)
*
6)
Electric Motors - Over 2 to 10 HP (1.5kw - 7.5kw)
Number of Electric Motors - Over 2 to 10 HP (1.5kw - 7.5kw)
*
7)
Electric Motors - Over 10 to 20 HP (>7.5kw - 14.9kw)
Number of Electric Motors - Over 10 to 20 HP (>7.5kw - 14.9kw)
*
8)
Electric Motors - Over 20 to 40 HP (> 14.9kw - 29.8kw)
Number of Electric Motors - Over 20 to 40 HP (> 14.9kw - 29.8kw)
*
9)
Hot Water Boiler - Less than 25kW
Number of Hot Water Boiler - Less than 25kW
*
10)
Hot Water Boiler - Over 25kW to 75kW
Number of Hot Water Boiler - Over 25kW to 75kW
*
11)
LPG Cylinders - Less than 25kg
Number of LPG Cylinders - Less than 25kg
*
12)
LPG Cylinders - Over 25kg up to 100kg
Number of LPG Cylinders - Over 25kg up to 100kg
*
13)
LPG Cylinders - Over 100kg
Number of LPG Cylinders - Over 100kg
*
14)
Pressure Vessels - Less than 2mtrs
Number of Pressure Vessels - Less than 2mtrs
*
15)
Pressure Vessels - from 2mtrs to 5mtrs
Number of Pressure Vessels - from 2mtrs to 5mtrs
*
16)
Sewerage Pumps
Number of Sewerage Pumps
*
17)
Submersible Pumps
Number of Submersible Pumps
*
18)
OTHER ITEMS
Description of Machinery below (include number of items)
*
Deterioration of Stock
Please Select
No cover required
Covered up to selected limit of:
Deterioration of Stock value
*
Deductible or Excess amount for this section (Machinery):
Please Select
$250 default value
$500
$750
$1,000
$2,000
$100
Do you wish to add any additional notes?
*
Yes
No
Notes:
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Electronic Equipment Cover Section
Accidental Damage to or Mechanical &/or Electrical breakdown of computers & associated equipment
Please select "Yes" to proceed with the Electronic Equipment Cover section...
*
Yes
No
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Electronic Equipment Cover Section
Specified Electronic Equipment Item #1
Classification
*
Please Select
Audio/Visual Equipment
Communication Systems
Computers other than laptops/tablet PCs
Diagnostic Equipment
Electronic Scales
Laptop/Tablet
Mobile Equipment anywhere in Aust (excl. laptops)
Office Equipment
Other
Sum Insured
*
Number of and Description of Item/s
*
Add another
Add
Specified Electronic Equipment Item #2
Classification
*
Please Select
Audio/Visual Equipment
Communication Systems
Computers other than laptops/tablet PCs
Diagnostic Equipment
Electronic Scales
Laptop/Tablet
Mobile Equipment anywhere in Aust (excl. laptops)
Office Equipment
Other
Sum Insured
*
Number of and Description of Item/s
Add another
Add
Specified Electronic Equipment Item #3
Classification
*
Please Select
Audio/Visual Equipment
Communication Systems
Computers other than laptops/tablet PCs
Diagnostic Equipment
Electronic Scales
Laptop/Tablet
Mobile Equipment anywhere in Aust (excl. laptops)
Office Equipment
Other
Sum Insured
*
Number of and Description of Item/s
Add OTHER
Add
Add more below
*
Loss of Electronic Data and Electronic Data Media coverage required?
*
Yes
No
Electronic Data sum insured
Electronic Data Media sum insured
Additional Increase in Cost of Working
*
Yes
No
Sum Insured
*
Indemnity Period (months)
*
Please Select
3
6
12
18
24
36
Excess in Days
*
Deductible or Excess amount for this section (Electronic Equipment):
Please Select
$250 default value
$500
$750
$1,000
$100
Do you wish to add more notes or upload a list of equipment or an invoice schedule ?
*
Yes
No
Notes:
Attachments
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Public and Products Liability Cover Section
Public Liability is described as Bodily injury and/or Property damage for which the insured is legally liable for and has arisen out of the insureds business activities.
Products Liability is Bodily injury and/or Property damage arising from the insureds products, which is anything manufactured, imported, modified, repackaged, grown or sold.
These two cover sections are packaged together and generally cannot be quoted in isolation of each other.
Please select "Yes" to proceed with the Public and Products Liability Cover section...
*
Yes
No
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Public and Products Liability Cover Section
Details of the Business for the purpose of calculating the Liability Premium Payable
Contractors and Sub-contractors
Do you engage contractors and/or sub-contractors in your business?
*
Yes
No
Do you ensure that contractors and/or subcontractors have their own liability and where necessary, Workers Compensation insurance?*
*
Yes
No
Estimate the amount to be paid to contractors and sub-contractors in the next 12 months:
*
Please Select
Labour Only
Labour and Plant
Labour, Plant and Materials
Est. Amount Paid for next 12 months
*
What type(s) of work do contractors and/or subcontractors perform for you?
Do the contractors and/or sub-contractors account for more than 25% of your total turnover?
*
Yes
No
Contractor and sub-contractor turnover*
*
Labour Hire
Do you engage labour hire or hired in labour in your business?
*
Yes
No
Estimate the amount to be paid to labour hire firms in the next 12 months
*
What type(s) of work do staff from labour hires perform for you?
Does the labour hire or hired labour account for more than 25% of your total turnover?*
*
Yes
No
Labour Hire and Hired Labour Turnover:
*
Designated Contracts
Do you have any contracts to be designated or are you required to sign up to a contractual agreement to perform work?
*
Yes
No
Description
Attachment upload
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Import Goods
Do you, or do you intend to import goods?
*
Yes
No
Imported Goods #1
Product description
*
Country imported from
*
Turnover
*
Add another
Add
Imported Goods #2
Product description
*
Country imported from
*
Turnover
*
Add another
Add
Imported Goods #3
Product description
*
Country imported from
*
Turnover
*
Broader description
Attachment
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Hazardous Activities and Substances
Do you, or do you intend to use, store or handle hazardous substances?
*
Yes
No
Describe the hazardous materials used and/or the hazardous waste produced:
*
Do you discharge waste or hazardous material into the atmosphere, sewer or elsewhere?
*
Yes
No
If Yes, please provide details:
*
Do you carry out any of the following: Use of explosives, bridge construction/maintenance, demolition activities, construction or maintenance work involving chemical works, defence,mines, offshore platforms, aircraft or aviation risks, utilities, gas production, petrochemicalplants, power stations, rail, ships or marine risks?
*
Yes
No
Please give details:
*
Do you perform "hot work" away from own premises that involves the use of cutting, welding, grinding or soldering equipment?
*
Yes
No
If Yes, describe the activities performed:
*
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Hire Out Equipment or Staff
Do you hire out equipment or hire out equipment and/or staff?
*
Yes
No
Is there a Hire Agreement with a disclaimer or legal waiver in place that the hirer signs before hiring?
*
Yes
No
Attachment
Is all equipment checked and maintained after each hire?
*
Yes
No
Describe Equipment hired out
Turnover
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Add
Describe Equipment hired out
Turnover
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Add
Describe Equipment hired out
Turnover
Add more detail
Add
Detail of Equipment and/or Labour Hire
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Other Details
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?
*
Yes
No
If Yes, Please provide details
*
Do you, or do you intend to export goods?
*
Yes
No
If Yes, please provide details
*
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.
*
Yes
No
Please provide details:
*
Upload an Attachment
Is the business authorised by its local government authority to place outdoor furniture (comprised of tables and chairs) and/or signs in a public place such as a footpath?
Yes
No
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Sum Insured
Limit of Liability - Public & Products Liability
*
Please Select
$5,000,000
$10,000,000
$15,000,000
$20,000,000
Other
Deductible or Excess amount for this section (Public and Products Liability):
Please Select
$500 default amount
$750
$1,000
$2,000
$5,000
$7,500
$10,000
$250
Do you wish to add any other information or notes?
Yes
No
Notes:
Upload an Attachment
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Glass Cover Section
Damage to fixed external or internal glass or both
Plus the cost of repair/replacement of sign writing on glass and/or security film and the like
Note: Most Lease Agreements will hold the tenant responsible for any damage to external glass
Please select "Yes" to proceed with the Glass Cover cover section...
*
Yes
No
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Glass Cover Section
Cover Type
*
Please Select
Internal & External Glass cover
Internal Glass only
External Glass only
Do you wish to add specified glass items?
*
Yes
No
Description
Add another
Add
Description
Add another
Add
Description
Signs
Please Select
Policy Wording Std Cover
Other Amount
Sum Insured for signs
*
Deductible or Excess amount for this section (Glass):
Please Select
$250 default amount
$500
$750
$1,000
$2,000
$100
Do you wish to add any notes?
*
Yes
No
Notes:
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General Property - Cover for Portable Equipment
Loss and/or damage to laptops & other portable equipment whilst away from the insured premises.
Please select "Yes" to proceed with the General Property Cover section...
*
Yes
No
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General Property - Cover for Portable Equipment
Cover types
*
Please Select
Unspecified Business Items only
Specified Business Items only
Specified and Unspecified Business Items
Sum Insured for Unspecified Items
*
Specified Business Item #1
Description
Type
*
Please Select
Laptops/Portable elect. equip (excl mobile phones/PDAs)
Mobile phones/PDAs
Tools of Trade excl. left on building site overnight
Tools of Trade incl. when left on building site overnight
Stock in Trade of Tradesman
Product Samples for Sales
Other
Sum Insured
*
Add another
Add
Specified Business Item #2
Description
Type
*
Please Select
Laptops/Portable elect. equip (excl mobile phones/PDAs)
Mobile phones/PDAs
Tools of Trade excl. left on building site overnight
Tools of Trade incl. when left on building site overnight
Stock in Trade of Tradesman
Product Samples for Sales
Other
Sum Insured
*
Add another
Add
Specified Business Item #3
Description
Type
*
Please Select
Laptops/Portable elect. equip (excl mobile phones/PDAs)
Mobile phones/PDAs
Tools of Trade excl. left on building site overnight
Tools of Trade incl. when left on building site overnight
Stock in Trade of Tradesman
Product Samples for Sales
Other
Sum Insured
Add another
Add
Specified Business Item #4
Description
Type
*
Please Select
Laptops/Portable elect. equip (excl mobile phones/PDAs)
Mobile phones/PDAs
Tools of Trade excl. left on building site overnight
Tools of Trade incl. when left on building site overnight
Stock in Trade of Tradesman
Product Samples for Sales
Other
Sum Insured
Cover Extensions
Australia Wide Cover
Australia Wide and Worldwide Cover
Deductible or Excess amount for this section (General Property):
*
Please Select
$250 default policy excess
$500
$1,000
$2,000
$100
Other Information
Do you wish to add any notes:
Yes
No
Notes:
Upload an Attachment
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Goods in Transit Cover Section
Damage to goods in transit locally and interstate, otherwise known as 'Inland Transit'
For Annual Marine Cargo cover which is more comprehensive than that within a business package insurance product, ask your insurance advisor
Please select "Yes" to proceed with the Goods in Transit Cover section...
*
Yes
No
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Goods in Transit Cover Section
Details of the business
Do you transport temperature controlled goods?
*
Yes
No
Estimated value of amount of goods sent in transit annually
*
Sum Insured
Cover Type
*
Accidental Damage
Limited Cover
Goods in Transit limit any one conveyance
$25,000
$50,000
$75,000
$100,000
$250,000
Excess
Please indicate the excess you prefer for Goods in Transit
Please Select
Default $250
$500
$1,000
$2,000
$5,000
$7,500
Other Information
Do you wish to provide any more information?
Yes
No
Notes
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Tax Audit Cover Section
Expenses due to unexpected tax audit (including GST)
Cover may be extended to include both Company Entity and personal taxation affairs of Company Directors
Please select "Yes" to proceed with the Tax Audit Cover section...
*
Yes
No
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Tax Audit Cover Section
Details of the business
Has the business &/or any director who will receive protection under this section had any previous Tax Audits?
Yes
No
Sum Insured
Tax Audit
Please Select
$10,000
$15,000
$20,000
$50,000
$100,000
Cover Type
Please Select
Business Audit Only
Business and Directors Audit
Audit of Individuals
Number of Directors
*
1
2
3
4
5
Director Name #1
Suburb
Select State
Please Select
QLD
NSW
VIC
TAS
SA
WA
NT
ACT
Postcode
Director Name #2
Suburb
Select State
Please Select
QLD
NSW
VIC
TAS
SA
WA
NT
ACT
Postcode
Director Name #3
Suburb
Select State
Please Select
QLD
NSW
VIC
TAS
SA
WA
NT
ACT
Postcode
Director Name #4
Suburb
Select State
Please Select
QLD
NSW
VIC
TAS
SA
WA
NT
ACT
Postcode
Director Name #5
Suburb
Select State
Please Select
QLD
NSW
VIC
TAS
SA
WA
NT
ACT
Postcode
Excess
Please indicate the excess you prefer for Tax Audit
Please Select
$0
$100
$250
$500
$1,000
$2,000
$5,000
$7,500
Do you wish to provide any other information
Yes
No
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Management Liability Cover Section
It's not only directors or officers of large public companies who may be exposed to personal liability. If you have a small to medium sized private company, you could be protected by a policy that covers claims from a wide range of management liabilities, such as;
* directors and officers liability
* company reimbursement
* company liability
* employment practice liability
* trustee liability
* fidelity (theft by employees), and
* business crisis consultant fees
Policy features may also include:
Cover for OH&S and pollution defence costs, including representation expenses and the insured persons’ pecuniary penalties (as permitted by law), and extension of cover for company pecuniary penalties (as permitted by law).
WHY CONSIDER THIS COVER:
For small businesses, the benefits of protection against legal costs involved in defending allegations of unfair dismissal of staff, harassment and bullying in the workplace are a good reason to consider this cover section.
Fines and Penalties can also be covered by this section provided that the defence of such a fine is permitted by law and the act causing the fine to be brought was unintentional and not malicious or reckless in nature. OH&S fines are the most common threat to a business for which this cover section incorporates protections against.
Please select "Yes" to proceed with the Management Liability Cover section...
*
Yes
No
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Management Liability Cover Section
Sum Insured
Management Liability
Please Select
$250,000
$500,000
$1,000,000
$2,000,000
$5,000,000
Other
If Other, please specify limit $
Cover Option
Employee Dishonesty amount insured (optional)
Please Select
Not Required
$10,000 limit
$25,000 limit
$50,000 limit
$75,000 limit
$100,000 limit
Other
Employee Dishonesty Limit Amount $
Deductible or EXCESS amount
Management Liability
Please Select
$0
$100
$250
$500
$1,000
$2,000
$5,000
$7,500
Employee Dishonesty
Please Select
$0
$100
$250
$500
$1,000
$2,000
$5,000
$7,500
Do you wish to provide any other information
Yes
No
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Declaration
I/we in effecting insurance in accordance with the information provided in this application declare and warrant:
A) The statements in this application form are true and correct;
B) I/we have disclosed all matters which to my/our knowledge the insurer should
be aware of;
C) That I/we agree to accept that Insurance Web Pty Ltd will use this information
in order to source insurance quotations from various insurance providers;
D) That I/we agree to accept that on receipt of our quotation for insurance cover
Insurance Web Pty Ltd shall also provide the relevant Product Disclosure
Statement and/or Policy Wording for the insurance cover quoted;
E) That I/we have access to and have read the relevant Financial Services Guide
supplied on the website:
www.insuranceweb.com.au
and also supplied at time
of quoting by email/fax/post.
Proposer's Signature:
Date:
-
Day
-
Month
Year
Date Picker Icon
Proposer's Title:
*
Below is to be hand completed on the hard copy printed form
Signature
Signed
X ...............................................................
Print name:
________________________________
Your Title: _____________________________
Dated: ......../......../..........
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