Small Farm
Insurance
Application
Application form filled in by
*
Please Select
Applicant
Insurance Web Representative
Other
Office staff member:
*
Please Select
Suzy Pratt
Sonya Wilmen
Jason Matthey
Travis Rock
Other
How did you hear about us?
*
Please Select
Searching online for insurance providers
Word of mouth referral
Yellow Pages online
Web Advertisement
Email marketing
Via "Fiducial Group"
Via "Total Advice Partners"
Via "10x Business Coaching"
Other
Information about completing this form on-line
Please show me more about the on-line process before I begin
Skip to begin entering data
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)
Back
Next
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.
Back
Next
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.
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.
Back
Next
Client Contact Details
First Name
*
Last Name
*
Enter your E-mail address
Contact phone number
*
Postal Address
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
*
Back
Next
Policy Level Details
Enter the date for your insurance cover to begin
-
Day
-
Month
Year
Date Picker Icon
Have you had home and contents insurance previously?
Yes
No
Previous Insurer:
*
Please Select
AAMI
Allianz
AMP
Anzvar
ANZ
AON
APIA
Budget Direct
Calliden
CGU
Chartis
CHUBB
Cole Insurance
CommInsure
Elders Insurance
GIO
NRMA
RACQ
Lumley
QBE
Real Insurance
Suncorp
TIO
Vero
Wesfarmers
Westpac
Woolworths
Youi
Other
Previous Due Date
-
Day
-
Month
Year
Date Picker Icon
Is this a new purchase?
Yes
No
What level of cover do you prefer?
*
Please Select
Accidental Damage Cover
Defined Events Only Cover
Other
Back
Next
Insured Details
Property Ownership
*
Private Individual/s
Company Owned
Enter the Trading Name
ABN (Australian Business Number)
Enter the full name of the most senior resident/property owner
*
Enter the date of birth of the most senior resident/property owner
*
-
Day
-
Month
Year
Date Picker Icon
Are you eligible for the Retiree Discount?
Please Select
No discount
Over 55 and no longer working
Are there other named insured persons to add?
No other insured/s
2 insured persons
3 insured persons
Enter the name of the second insured individual
Enter the date of birth of the second insured individual
-
Day
-
Month
Year
Date Picker Icon
Enter the name of the third insured individual
Enter the date of birth of the third insured individual
-
Day
-
Month
Year
Date Picker Icon
Back
Next
Occupancy Type and Interested Parties
Occupancy:
*
Please Select
I live in this rented house
I own and occupy this home
The home is an investment property
Enter the weekly rental income for this property
Is the property managed by a Licensed Property Management Agent?
Yes
No
Has the property been or is the property likely to be unoccupied for more than a period of 60 consecutive days?
*
Yes
No
Is the property part of a Strata Title
*
Yes
No
Are there any financial interested parties to note on the policy?
*
Yes
No
Details of Interested Party
Back
Next
Situation Address Details
Enter the details of the
property situation address
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 Flood Coverage required for this location?
*
Yes
No
Is the home connected to a town mains water supply?
Yes
No
Back
Next
Claims History and General Information
Has the insured had any home related claims in the last 5 years?:
*
Yes
No
Please provide a description, the date and amount of the claim/s
Has any insurance company refused to meet a claim or circumstance lodged by you or by any entity / person named as the proposer herein, in respect of the classes of insurance applied for in this application?
*
Yes
No
Please provide details to the Yes response above
Has any insurance company succeeded in denying a claim or circumstance lodged by you or any person or entity named as the proposer herein on the grounds of non-disclosure, misrepresentation and/or fraud, in respect of these classes of insurance?
*
Yes
No
Please provide details to the Yes response above
Have there been any incidents for Property, Legal Liability or otherwise over the past 5 year history for which you could have claimed but did not?
*
Yes
No
Please provide details to the Yes response above
You have stated that no claims have occurred over the past five year history at this property address
Back
Next
Building Attributes of Property to be Insured
Enter the year built
*
Is the building subject to a National Trust Classification or Heritage Listing?
Yes
No
Please tell us more about the Heritage Listing
Is the building being let or rented on a commercial basis (for example, bed and breakfast, hotels, hostels, motels, guest houses or boarding houses, etc)?
Yes
No
Dwelling Type?
*
Please Select
House on Slab/Foundations
House on Poles
Townhouse/Villa
Duplex/triplex/quadplex (side by side dwellings only)
Unit/apartment/flat - above ground level
Unit/apartment/flat - ground level
Secured unit/apartment (security gates & controlled entry)
Weekender/holiday home- Family Use only- non income producing
Weekender/Holiday home- income producing
Weekender/holiday home- family and other us- non income producing
House with farm or hobby farm- nil income earned
House with farm or hobby farm- any income earned
House with a jetty attached
Bed & breakfast- No more than two bedrooms are used for the business activity
Historical dwelling
Classified buildings (eg National Trust)
Display home- with sales office on or in the property
Display home- no sales office and occupied
Display home- no sales office and unoccupied
Guest house
House with detached flat
Mobile home
Nursing home
Relocatable home or Caravan
Retirement Village, Unit/Villa
Nursing Home Unit/Villa
Boarding house
Other
Is the Building located on property/land greater than 5 acres or 20,000 square metres?
Yes
No
Is the building watertight, well maintained, structurally sound and secure?
Yes
No
Please provide more detail to the condition of the property:
Select one of the following options in relation to the building:
*
Please Select
Completed. Not under any type of construction.
Lock up stage - awaiting owners/tenants to move in.
Under construction work where the value of works do not exceed $50,000
Under construction work where the value of works exceed $50,000
Display Home and/or Real Estate Sales office location
Does the property have a Swimming Pool?
*
Yes
No
Please check any features which apply to the swimming pool and its surroundings
Pool has compliant pool fencing
First Aid/CPR signs displayed clearly near the pool
Depth Indicators are visible in the pool area
No Running / No Diving Signs displayed
Night time lighting around the pool
Is any part of the building used for any business, trade or profession, other than a home office?
Yes
No
Please provide more information about business activities
Back
Next
Construction Details
Building Construction type
*
Please Select
Mixed - combination of these
Aluminium
Brick
Brick Veneer
BlueBoard
Cladding
Concrete
Fibro/Asbestos
Fibre Cement
Hardiplank/hardiflex
Iron
Metal
Mud Brick
Rock/Stone
Rockcote
Timber
Weatherboard
Other
Tick all building materials
Aluminium
Brick
Brick Veneer
BlueBoard
Cladding
Concrete
Fibro/Asbestos
Fibre Cement
Hardiplank
Hardiflex
Iron
Metal
Mud Brick
Rock/Stone
Rockcote
Timber
Weatherboard
Roof Construction type
*
Please Select
Aluminium
Cliplock
Concrete
Decramastic
Fibro/Asbestos Cement
Iron (corrugated)
Shingles
Slate
Steel/Colorbond
Tiles
Timber
Other
Building height in stories
Please Select
Single Level Building
Double Storey
Three Levels
More than three levels
Floor Construction type
*
Please Select
Concrete
Timber
Other
Floor type for other levels of the building
Please Select
Concrete
Timber
Mixed
Other
How many bedrooms does the home have including study?
What is the floor plan size including the garage area and any sheds in m2?
Back
Next
Security Details
Window Locks
*
Please Select
Keyed locks or security screens/grills on all windows
Keyed locks or security screens/grills on some windows
No keyed locks or security screens/grills on windows
Other
Door Locks
*
Please Select
Dead locks fitted to some external doors
Double keyed deadlocks fitted to all external doors
No deadlocks fitted to doors
Single keyed deadlocks fitted to all external doors
Other
Alarm System
*
Please Select
Back to base/monitored alarm system installed
Local alarm system installed (ie: not back to base)
No alarm is installed
Smoke Detectors
*
Please Select
None
Battery Operated Smoke Alarms
Hard Wired Smoke Alarms
Hard Wired Smoke Alarms with back to base monitoring system
Back
Next
Details of Coverage Required
Building Sum Insured
Is Mortgage Protection only cover required?
Yes
No
Contents Sum Insured
Do you have single items or set of items situated within the home worth over $10,000 such as works of art, items of historical value etc.
Yes
No
List any items you wish to specify within the home along with an approx value.
Do you require cover for Specified Valuables away from the home
*
Yes
No
Please Select
Bicycles or Sporting Equipment
Binoculars and Telescopes
Cameras and/or Video Equipment
Furs
Jewellery
Musical Instruments
Portable Electrical Items
Sunglasses of high value
High Value Watches
Other or more details:
Please detail any valuables and their amount you would like to specify
Do you wish to insure for Tenants Rent Default cover?
*
Yes
No
Do you wish to insure for malicious damage by Tenants?
Yes
No
Attachments (add files to go with your quotation submission to us)
Select File
Cancel
of
More information:
Back
Next
Farm Property Cover Section
Farm Location
Name of Farm:
Address Line 1:
*
Address Line 2:
Town/Suburb:
*
Post Code:
*
State:
*
Please Select
QLD
NSW
VIC
TAS
WA
SA
ACT
NT
Financial Interests
Is there a mortgage on the farm?
Yes
No
Name of Mortgagee
Mortgage No.
Address Line 1:
Address Line 2:
Town/Suburb:
Post Code:
State:
Please Select
QLD
NSW
VIC
TAS
WA
SA
ACT
NT
Add another mortgage?
1
Name of Mortgagee
Mortgage No.
Address Line 1:
Address Line 2:
Town/Suburb:
Post Code:
State:
Please Select
QLD
NSW
VIC
TAS
WA
SA
ACT
NT
Add another mortgage?
1
Name of Mortgagee
Mortgage No.
Address Line 1:
Address Line 2:
Town/Suburb:
Post Code:
State:
Please Select
QLD
NSW
VIC
TAS
WA
SA
ACT
NT
Back
Next
Part A Farm Structures and Farm Contents
Farm Buildings (excl.coolrooms) Sum Insured:
Number of Buildings
Coolrooms Sum Insured:
Number of Coolrooms
Enter Building Details:
Yes
No
Building 1 Description:
Sum Insured:
Is this building a coolroom?
Yes
No
Add Another?
1
Building 2 Description:
Sum Insured:
Is this building a coolroom?
Yes
No
Add Another?
1
Building 3 Description:
Sum Insured:
Is this building a coolroom?
Yes
No
Add Another?
1
Building 4 Description:
Sum Insured:
Is this building a coolroom?
Yes
No
Add Another?
1
Building 5 Description:
Sum Insured:
Is this building a coolroom?
Yes
No
Do you confirm that all Farm Structures to be insured are structurally sound, are well maintained and have no un-repaired damage?
Yes
No
Value of fences per km.
Total Length (kms)
Fences (not hedges) Sum Insured:
**Other Farm Structures Sum Insured:
Farm Contents Sum Insured:
Hail Netting stored in a structure with roof and walls (Fire Only) Sum Insured:
Hail Netting in the Open Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Back
Next
Part B Farm Machinery
Unspecified Machinery (Limit $5,000 Per Item) Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Specified Machinery (Over $5,000 Per Item) Total Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Please enter the details of specified items below:
Item Description:
Year:
Serial Number:
Sum Insured:
Add Another?
1
Item Description:
Year:
Serial Number:
Sum Insured:
Add Another?
1
Item Description:
Year:
Serial Number:
Sum Insured:
Back
Next
Part C Livestock
Total Livestock Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Type of Livestock
Please Select
Alpacas
Bulls
Calves
Cattle
Deer
Ewes
Goats
Heifers
Hogs
Horses
Lambs
Ostriches
Pigs
Poultry
Rams
Sheep
Sows
Steers
Vealers
Wethers
No. of Animals
Sum Insured Per Animal
Add Another?
1
Type of Livestock
Please Select
Alpacas
Bulls
Calves
Cattle
Deer
Ewes
Goats
Heifers
Hogs
Horses
Lambs
Ostriches
Pigs
Poultry
Rams
Sheep
Sows
Steers
Vealers
Wethers
No. of Animals
Sum Insured Per Animal
Add Another?
1
Type of Livestock
Please Select
Alpacas
Bulls
Calves
Cattle
Deer
Ewes
Goats
Heifers
Hogs
Horses
Lambs
Ostriches
Pigs
Poultry
Rams
Sheep
Sows
Steers
Vealers
Wethers
No. of Animals
Sum Insured Per Animal
Add Another?
1
Type of Livestock
Please Select
Alpacas
Bulls
Calves
Cattle
Deer
Ewes
Goats
Heifers
Hogs
Horses
Lambs
Ostriches
Pigs
Poultry
Rams
Sheep
Sows
Steers
Vealers
Wethers
No. of Animals
Sum Insured Per Animal
Add Another?
1
Type of Livestock
Please Select
Alpacas
Bulls
Calves
Cattle
Deer
Ewes
Goats
Heifers
Hogs
Horses
Lambs
Ostriches
Pigs
Poultry
Rams
Sheep
Sows
Steers
Vealers
Wethers
No. of Animals
Sum Insured Per Animal
Add Another?
1
Type of Livestock
Please Select
Alpacas
Bulls
Calves
Cattle
Deer
Ewes
Goats
Heifers
Hogs
Horses
Lambs
Ostriches
Pigs
Poultry
Rams
Sheep
Sows
Steers
Vealers
Wethers
No. of Animals
Sum Insured Per Animal
Add Another?
1
Type of Livestock
Please Select
Alpacas
Bulls
Calves
Cattle
Deer
Ewes
Goats
Heifers
Hogs
Horses
Lambs
Ostriches
Pigs
Poultry
Rams
Sheep
Sows
Steers
Vealers
Wethers
No. of Animals
Sum Insured Per Animal
Add Another?
1
Type of Livestock
Please Select
Alpacas
Bulls
Calves
Cattle
Deer
Ewes
Goats
Heifers
Hogs
Horses
Lambs
Ostriches
Pigs
Poultry
Rams
Sheep
Sows
Steers
Vealers
Wethers
No. of Animals
Sum Insured Per Animal
Add Another?
1
Type of Livestock
Please Select
Alpacas
Bulls
Calves
Cattle
Deer
Ewes
Goats
Heifers
Hogs
Horses
Lambs
Ostriches
Pigs
Poultry
Rams
Sheep
Sows
Steers
Vealers
Wethers
No. of Animals
Sum Insured Per Animal
Back
Next
Part D Working Dogs
Number of working Dogs:
Cover per dog Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Part E Harvested Crops
Total Cover Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Part F Beehives
Number of Beehives:
Total Cover Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Optional Extras
Portable Items:
Yes
No
Dog Attack:
Yes
No
Back
Next
Farm Interruption Cover Section
Part A - Loss of Farm Income
Your expected Farm Income for the next year is:
(Excluding Agistment Income)
Indemnity Period (months)
6
9
12
18
24
Total Cover Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Part B - Loss of Agistment Income
Your expected Agistment Income for the next year is:
Indemnity Period (months)
6
9
12
18
24
Total Cover Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Part B - Extra Costs
Indemnity Period (months)
6
9
12
18
24
Total Cover Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Part D - Shearing Delays
Total Cover Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Back
Next
Money Cover Section
Cover for Your Money
At the location of the Farm Sum Insured:
In a locked safe or strongroom at the Location Sum Insured:
In direct transit between the Location, a bank or other financial institution, market or sales yard Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Back
Next
Farm Liability Cover Section
Part A - General Liability
General Liability Cover Limit of Indemnity:
Please Select
$5,000,000
$10,000,000
$20,000,000
Part B - Products Liability
Do you need products liability cover:
Yes
No
Please select the products sold:
Farm Produce
Livestock
Other
Products Liability Cover Limit of Indemnity:
Please Select
$5,000,000
$10,000,000
$20,000,000
Optional Extras
Do you have paying guests?
Yes
No
Where do the guests stay?
Your Home
A separate home on the farm
In Caravans
Camping Facilities
Other
Does the accommodation facility comply with local council regulations?
Yes
No
Is your facility a Holiday Farm?
Yes
No
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Back
Next
Burglary Cover Section
Do you wish to cover your property against loss or accidental damage caused by Burglary?
Yes
No
Optional Extras
Theft of Farm Structures and Farm Contents?
Yes
No
Theft of Farm Machinery?
Yes
No
Portable Items?
Yes
No
Back
Next
Farm Machinery Cover Section
Part A - Machinery Breakdown
Make
Type of Machinery
Please Select
All Terrain Vehicle
Auger
Backhoe
Bobcat
Bulldozer
Bus
Cane Harvester
Caravan
Chaser Bin
Cherry Picker
Chipper
Compactor
Cotton Picker
Elevator
Excavator
Field Bin
Forklift
Grader
Grape Harvester
Header
Listed Vehicle
Loader
Mobile Crane
Motor Scooter
Motorcycle
Motordrawn Farm Implement
Mower
Mulcher
Nut Harvester
Onion Harvester
Pivot Irrigation
Roller
Round Baler
Scraper
Spray Unit
Square Baler
Tomato Harvester
Tractor
Trailer
Travelling Irrigator
Trencher
Truck
Truck Mounted Implements
Windrower
Year Made
Engine Size (Litres)
No. of Cylinders
Purchase Price
Description
Add Another
1
Make
Type of Machinery
Please Select
All Terrain Vehicle
Auger
Backhoe
Bobcat
Bulldozer
Bus
Cane Harvester
Caravan
Chaser Bin
Cherry Picker
Chipper
Compactor
Cotton Picker
Elevator
Excavator
Field Bin
Forklift
Grader
Grape Harvester
Header
Listed Vehicle
Loader
Mobile Crane
Motor Scooter
Motorcycle
Motordrawn Farm Implement
Mower
Mulcher
Nut Harvester
Onion Harvester
Pivot Irrigation
Roller
Round Baler
Scraper
Spray Unit
Square Baler
Tomato Harvester
Tractor
Trailer
Travelling Irrigator
Trencher
Truck
Truck Mounted Implements
Windrower
Year Made
Engine Size (Litres)
No. of Cylinders
Purchase Price
Description
Add Another
1
Type of Machinery
Please Select
All Terrain Vehicle
Auger
Backhoe
Bobcat
Bulldozer
Bus
Cane Harvester
Caravan
Chaser Bin
Cherry Picker
Chipper
Compactor
Cotton Picker
Elevator
Excavator
Field Bin
Forklift
Grader
Grape Harvester
Header
Listed Vehicle
Loader
Mobile Crane
Motor Scooter
Motorcycle
Motordrawn Farm Implement
Mower
Mulcher
Nut Harvester
Onion Harvester
Pivot Irrigation
Roller
Round Baler
Scraper
Spray Unit
Square Baler
Tomato Harvester
Tractor
Trailer
Travelling Irrigator
Trencher
Truck
Truck Mounted Implements
Windrower
Year Made
Engine Size (Litres)
No. of Cylinders
Purchase Price
Description
Back
Next
Machinery Cover Section
Part A - Machinery Breakdown
Milking Sheds
Including above ground motors, above ground pumps and milk vat refrigeration units
Volume (Litres)
Please Select
Up to 2,000
2,001 to 4,000
Over 4,001
Other
Number of Vats
Please Select
1
2
3
Other
Sum Insured Per Unit
Please Select
$10,000
$20,000
Other
Volume (Litres)
Please Select
Up to 2,000
2,001 to 4,000
Over 4,001
Other
Number of Vats
Please Select
1
2
3
Other
Sum Insured Per Unit
Please Select
$10,000
$20,000
Other
Volume (Litres)
Please Select
Up to 2,000
2,001 to 4,000
Over 4,001
Other
Number of Vats
Please Select
1
2
3
Other
Sum Insured Per Unit
Please Select
$10,000
$20,000
Other
Shearing Sheds
Number of Shearing Stands:
Sum Insured Per Unit:
Wool Presses are included automatically with shearing stands
Specified Items
Add Unit/s
1
Description of Unit
Please Select
Air Conditioner
Compressor
Cool Room
Electric Motor
Evaporator Cooler
Generator
Pump - Above Ground
Pump - Submersible
Refrigeration Unit
Other
Sum Insured for Individual Units
No. of Units
Rated Power (kw)
Please Select
<3HP (2.4kw)
3HP (2.4kw) to 5HP (3.7kw)
5HP (3.7kw) to 10HP (7.5kw)
10HP (7.5kw) to 15HP (11.2kw)
15HP (11.2kw) to 20HP (14.9kw)
>20HP (14.9kw)
If more than 20 HP (14.9kw) please state the power rating of the unit/s:
Add Another
1
Description of Unit
Please Select
Air Conditioner
Compressor
Cool Room
Electric Motor
Evaporator Cooler
Generator
Pump - Above Ground
Pump - Submersible
Refrigeration Unit
Other
Sum Insured for Individual Units
No. of Units
Rated Power (kw)
Please Select
<3HP (2.4kw)
3HP (2.4kw) to 5HP (3.7kw)
5HP (3.7kw) to 10HP (7.5kw)
10HP (7.5kw) to 15HP (11.2kw)
15HP (11.2kw) to 20HP (14.9kw)
>20HP (14.9kw)
If more than 20 HP (14.9kw) please state the power rating of the unit/s:
Add Another
1
Description of Unit
Please Select
Air Conditioner
Compressor
Cool Room
Electric Motor
Evaporator Cooler
Generator
Pump - Above Ground
Pump - Submersible
Refrigeration Unit
Other
Sum Insured for Individual Units
No. of Units
Rated Power (kw)
Please Select
<3HP (2.4kw)
3HP (2.4kw) to 5HP (3.7kw)
5HP (3.7kw) to 10HP (7.5kw)
10HP (7.5kw) to 15HP (11.2kw)
15HP (11.2kw) to 20HP (14.9kw)
>20HP (14.9kw)
If more than 20 HP (14.9kw) please state the power rating of the unit/s:
Add Another
1
Description of Unit
Please Select
Air Conditioner
Compressor
Cool Room
Electric Motor
Evaporator Cooler
Generator
Pump - Above Ground
Pump - Submersible
Refrigeration Unit
Other
Sum Insured for Individual Units
No. of Units
Rated Power (kw)
Please Select
<3HP (2.4kw)
3HP (2.4kw) to 5HP (3.7kw)
5HP (3.7kw) to 10HP (7.5kw)
10HP (7.5kw) to 15HP (11.2kw)
15HP (11.2kw) to 20HP (14.9kw)
>20HP (14.9kw)
If more than 20 HP (14.9kw) please state the power rating of the unit/s:
Add Another
1
Description of Unit
Please Select
Air Conditioner
Compressor
Cool Room
Electric Motor
Evaporator Cooler
Generator
Pump - Above Ground
Pump - Submersible
Refrigeration Unit
Other
Sum Insured for Individual Units
No. of Units
Rated Power (kw)
Please Select
<3HP (2.4kw)
3HP (2.4kw) to 5HP (3.7kw)
5HP (3.7kw) to 10HP (7.5kw)
10HP (7.5kw) to 15HP (11.2kw)
15HP (11.2kw) to 20HP (14.9kw)
>20HP (14.9kw)
If more than 20 HP (14.9kw) please state the power rating of the unit/s:
Back
Next
Part B - Boiler
Enter Boiler Items?
Yes
No
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Type of Plant
Please Select
Hot Water Boiler
Pipe Systems
Steam Boiler
Steam Generator
Make:
Model:
Rated Power (kw)
Please Select
20 - 25kw
25 - 30kw
30 - 35kw
35+ kw
Pipe System Length (Metres)
No. of Units
Sum Insured Per Unit
Add Another?
1
Type of Plant
Please Select
Hot Water Boiler
Pipe Systems
Steam Boiler
Steam Generator
Make:
Model:
Rated Power (kw)
Please Select
20 - 25kw
25 - 30kw
30 - 35kw
35+ kw
Pipe System Length (Metres)
No. of Units
Sum Insured Per Unit
Add Another?
1
Type of Plant
Please Select
Hot Water Boiler
Pipe Systems
Steam Boiler
Steam Generator
Make:
Model:
Rated Power (kw)
Please Select
20 - 25kw
25 - 30kw
30 - 35kw
35+ kw
Pipe System Length (Metres)
No. of Units
Sum Insured Per Unit
Add Another?
1
Type of Plant
Please Select
Hot Water Boiler
Pipe Systems
Steam Boiler
Steam Generator
Make:
Model:
Rated Power (kw)
Please Select
20 - 25kw
25 - 30kw
30 - 35kw
35+ kw
Pipe System Length (Metres)
No. of Units
Sum Insured Per Unit
Add Another?
1
Type of Plant
Please Select
Hot Water Boiler
Pipe Systems
Steam Boiler
Steam Generator
Make:
Model:
Rated Power (kw)
Please Select
20 - 25kw
25 - 30kw
30 - 35kw
35+ kw
Pipe System Length (Metres)
No. of Units
Sum Insured Per Unit
Add Another?
1
Type of Plant
Please Select
Hot Water Boiler
Pipe Systems
Steam Boiler
Steam Generator
Make:
Model:
Rated Power (kw)
Please Select
20 - 25kw
25 - 30kw
30 - 35kw
35+ kw
Pipe System Length (Metres)
No. of Units
Sum Insured Per Unit
Add Another?
1
Type of Plant
Please Select
Hot Water Boiler
Pipe Systems
Steam Boiler
Steam Generator
Make:
Model:
Rated Power (kw)
Please Select
20 - 25kw
25 - 30kw
30 - 35kw
35+ kw
Pipe System Length (Metres)
No. of Units
Sum Insured Per Unit
Add Another?
1
Type of Plant
Please Select
Hot Water Boiler
Pipe Systems
Steam Boiler
Steam Generator
Make:
Model:
Rated Power (kw)
Please Select
20 - 25kw
25 - 30kw
30 - 35kw
35+ kw
Pipe System Length (Metres)
No. of Units
Sum Insured Per Unit
Add Another?
1
Type of Plant
Please Select
Hot Water Boiler
Pipe Systems
Steam Boiler
Steam Generator
Make:
Model:
Rated Power (kw)
Please Select
20 - 25kw
25 - 30kw
30 - 35kw
35+ kw
Pipe System Length (Metres)
No. of Units
Sum Insured Per Unit
Add Another?
1
Type of Plant
Please Select
Hot Water Boiler
Pipe Systems
Steam Boiler
Steam Generator
Make:
Model:
Rated Power (kw)
Please Select
20 - 25kw
25 - 30kw
30 - 35kw
35+ kw
Pipe System Length (Metres)
No. of Units
Sum Insured Per Unit
Part C - Refrigerated Farm Produce
Cover for milk in Vats Sum Insured:
Cover for all other produce:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Back
Next
Electronics Cover Section
Part A - Electronic Equipment
Type of Equipment:
Please Select
Audio Visual Equipment
Computer Peripheral
Desktop Computer
Electronic Cash Register
Electronic Controller
Electronic Scales
Fax Machine
Laser Level
Laser Theodolite
Notebook Computer
Photocopier
Printer
Telephone Equipment
Other
Make:
Serial Number
No. of Units
Portable Equipment to be covered anywhere in Australia?
Yes
No
Add Another?
1
Type of Equipment:
Please Select
Audio Visual Equipment
Computer Peripheral
Desktop Computer
Electronic Cash Register
Electronic Controller
Electronic Scales
Fax Machine
Laser Level
Laser Theodolite
Notebook Computer
Photocopier
Printer
Telephone Equipment
Other
Make:
Serial Number
No. of Units
Portable Equipment to be covered anywhere in Australia?
Yes
No
Add Another?
1
Type of Equipment:
Please Select
Audio Visual Equipment
Computer Peripheral
Desktop Computer
Electronic Cash Register
Electronic Controller
Electronic Scales
Fax Machine
Laser Level
Laser Theodolite
Notebook Computer
Photocopier
Printer
Telephone Equipment
Other
Make:
Serial Number
No. of Units
Portable Equipment to be covered anywhere in Australia?
Yes
No
Add Another?
1
Type of Equipment:
Please Select
Audio Visual Equipment
Computer Peripheral
Desktop Computer
Electronic Cash Register
Electronic Controller
Electronic Scales
Fax Machine
Laser Level
Laser Theodolite
Notebook Computer
Photocopier
Printer
Telephone Equipment
Other
Make:
Serial Number
No. of Units
Portable Equipment to be covered anywhere in Australia?
Yes
No
Add Another?
1
Type of Equipment:
Please Select
Audio Visual Equipment
Computer Peripheral
Desktop Computer
Electronic Cash Register
Electronic Controller
Electronic Scales
Fax Machine
Laser Level
Laser Theodolite
Notebook Computer
Photocopier
Printer
Telephone Equipment
Other
Make:
Serial Number
No. of Units
Portable Equipment to be covered anywhere in Australia?
Yes
No
Add Another?
1
Type of Equipment:
Please Select
Audio Visual Equipment
Computer Peripheral
Desktop Computer
Electronic Cash Register
Electronic Controller
Electronic Scales
Fax Machine
Laser Level
Laser Theodolite
Notebook Computer
Photocopier
Printer
Telephone Equipment
Other
Make:
Serial Number
No. of Units
Portable Equipment to be covered anywhere in Australia?
Yes
No
Add Another?
1
Type of Equipment:
Please Select
Audio Visual Equipment
Computer Peripheral
Desktop Computer
Electronic Cash Register
Electronic Controller
Electronic Scales
Fax Machine
Laser Level
Laser Theodolite
Notebook Computer
Photocopier
Printer
Telephone Equipment
Other
Make:
Serial Number
No. of Units
Portable Equipment to be covered anywhere in Australia?
Yes
No
Add Another?
1
Type of Equipment:
Please Select
Audio Visual Equipment
Computer Peripheral
Desktop Computer
Electronic Cash Register
Electronic Controller
Electronic Scales
Fax Machine
Laser Level
Laser Theodolite
Notebook Computer
Photocopier
Printer
Telephone Equipment
Other
Make:
Serial Number
No. of Units
Portable Equipment to be covered anywhere in Australia?
Yes
No
Add Another?
1
Type of Equipment:
Please Select
Audio Visual Equipment
Computer Peripheral
Desktop Computer
Electronic Cash Register
Electronic Controller
Electronic Scales
Fax Machine
Laser Level
Laser Theodolite
Notebook Computer
Photocopier
Printer
Telephone Equipment
Other
Make:
Serial Number
No. of Units
Portable Equipment to be covered anywhere in Australia?
Yes
No
Add Another?
1
Type of Equipment:
Please Select
Audio Visual Equipment
Computer Peripheral
Desktop Computer
Electronic Cash Register
Electronic Controller
Electronic Scales
Fax Machine
Laser Level
Laser Theodolite
Notebook Computer
Photocopier
Printer
Telephone Equipment
Other
Make:
Serial Number
No. of Units
Portable Equipment to be covered anywhere in Australia?
Yes
No
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Part A - Loss of Data
Total Cover Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Back
Next
Transit Cover Section
Part A - Livestock
Maximum value for any one load Sum Insured:
Part B - Farm Product and Machinery
Maximum value for any one load Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
$5,000
$10,000
Back
Next
Livestock Cover Section
Livestock Cover is also available within this Farm Protection Policy, please select "Yes" below if you would like to hear more about the type of cover available when one of our friendly staff contact you regarding this application...
Would you like to know more about this type of cover?
*
Yes
No
Back
Next
Valuables Cover Section
Details of Cover
Do you wish to cover mobile phones, laptop computers and portable GPS units?
Yes
No
Cover for mobile phones, laptop computers and portable GPS units Sum Insured:
Cover for unspecified items Sum Insured:
Cover for specified items Sum Insured:
Excess:
Please Select
$250
$500
$1,000
$2,000
Please list specified items to be covered...
Item 1 Description:
Item 1 Sum Insured:
Add Another?
1
Item 2 Description:
Item 2 Sum Insured:
Add Another?
1
Item 3 Description:
Item 3 Sum Insured:
Add Another?
1
Item 4 Description:
Item 4 Sum Insured:
Add Another?
1
Item 5 Description:
Item 5 Sum Insured:
Add Another?
1
Item 6 Description:
Item 6 Sum Insured:
Add Another?
1
Item 7 Description:
Item 7 Sum Insured:
Add Another?
1
Item 8 Description:
Item 8 Sum Insured:
Add Another?
1
Item 9 Description:
Item 9 Sum Insured:
Add Another?
1
Item 10 Description:
Item 10 Sum Insured:
Back
Next
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:
-
Month
-
Day
Year
Date
Proposer"s Title:
*
Below is to be hand completed on the hard copy printed form
Signature/s
Signed:
X .................................................................
Print name/s:
________________________________
Dated: ......../......../..........
End of form data
You may now review the form going back through details or simply submit the form by clicking the SUBMIT button below.
Back
Next
Submit
Should be Empty: