2 A General Business Insurance Application

General Business Insurance Application
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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)

Important - please read before completing this form
PrivacyWe 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.

Duty of DisclosureBefore 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 usIt 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 MisrepresentationIf 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 policyWhen 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 policyYou 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 MisrepresentationIf 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 SectionPlease 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 DetailsFor 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.

Proposed Policy Start Date
Enter the proposed start date for insurance cover or the expiry date of the existing policy*

DayMonthYear
Your Contact Information
First Name*
Last Name*
Enter your E-mail address
Contact phone number*
Enter the name of the current insurer*

Situation Address of the principal place of operations
Address Line 1*
Address Line 2
Enter Suburb or City*
Select State*
Enter Postcode*
Is the mailing address different from the principal place of operations?*

YesNo
Please enter your mailing address details
Mail Address Line One*
Mail Address Line Two
Enter Suburb or mail centre location*
Select Mail State*
Enter Mail Postcode*

Details of those proposed to be insured
Please select the type of Entity to be insured*
Enter the Name of the Business*
Enter your First Name/s*
Surname*
Enter the Trading Name*
Website address (if you have one)
ABN (Australian Business Number)
Registered for GST?

YesNo
Approx date which the Proposer Commenced Business Operations

DayMonthYear
Does the business have a Stamp Duty Exemption?

YesNo
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Claims Experience
Any claims in the last 5 years under the sections to be insured?*

YesNo
Number of claims in the past 5 years*
Claim #1
Cover section claimed under*
Date of Loss*

DayMonthYear
Amount Incurred*
Please provide details*
Preventative/Corrective action details*
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Claim #2
Cover section claimed under
Date of Loss

DayMonthYear
Amount Incurred
Please provide details*
Preventative/Corrective action details
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Claim #3
Cover section claimed under
Date of Loss

DayMonthYear
Amount Incurred
Please provide details
Preventative/Corrective action details
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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
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Demographic of Business Operations per State in Australia
Number of locations
Please list other property locations
Please check those that apply, including the principal base state of operations

QLDNSWACTVICTASSAWANTOverseas
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 %

Construction Details
Are there Multiple Buildings on this site*

NoYes
Approx Year Built (yyyy)*
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)?*

Building Details
Number of Stories*
Floors*
Walls*
Roof*

Interested Parties
Nature of Interest
Full Name of Interested Party
Address Line 1
Address Line 2
Suburb
State
Postcode
Add another interested party

YesNo
Nature of Interest
Details of other Interested Parties:

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 this cover section...*

YesNo

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 this cover section...*

YesNo

Business Interruption Cover Section
Type of Cover*
Insurable Gross Profit sum insured:*
Indemnity Period (months)*
Annual Revenue sum insured:*
Indemnity Period (months)*
Weekly Revenue sum insured:*
Additional Increase in cost of working
Indemnity Period (weeks)*
Loss of Rent Receivable
Accounts Receivable
Claims Preparation Costs
Additional Benefits
Documents
Specified Amount
Optional Benefit
Goodwill
Add any Attachments

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Unspecified / Specified Customers and Suppliers
Do you wish to specify any Customers or Suppliers?

YesNo
Customer / Supplier #1 Please enter the Name, Address, Suburb, State, Postcode and Country of the Customer or Supplier followed by the Goods Supplied and Percentage % of dependency.
Customer / Supplier #2 Please enter the Name, Address, Suburb, State, Postcode and Country of the Customer or Supplier followed by the Goods Supplied and Percentage % of dependency.
Customer / Supplier #3 Please enter the Name, Address, Suburb, State, Postcode and Country of the Customer or Supplier followed by the Goods Supplied and Percentage % of dependency.

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 this cover section...*

YesNo

Money Cover Section
Loss or damage to cash, cheques and negotiable instruments.
Please select "Yes" to proceed with Money cover section...*

YesNo

Money Cover Section
Type of Cover*
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
Money in Custody
Deductible or Excess amount for this section (Money):
Do you wish to add any notes?

YesNo
Notes:

Machinery Breakdown Cover Section
Repair costs incurred following breakdown of plant & equipment Air ConditioningRefrigeration Equipmentand others Optional extension of cover:Deterioration of Stock resulting from the breakdown of refrigeration
Please select "Yes" to proceed with this cover section...*

YesNo

Electronic Equipment Cover Section
Accidental Damage to or Mechanical &/or Electrical breakdown of computers & associated equipment
Please select "Yes" to proceed with this cover section...*

YesNo

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 this cover section...*

YesNo

Import Goods
Do you, or do you intend to import goods?*

YesNo
Imported Goods #1
Product description*
Country imported from*
Turnover*
Add another

Option 1Option 2Option 3
Imported Goods #2
Product description*
Country imported from*
Turnover*
Add another

Option 1Option 2Option 3
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?*

YesNo
Describe the hazardous materials used and/or the hazardous waste produced:*
Do you discharge waste or hazardous material into the atmosphere, sewer or elsewhere?*

YesNo
If Yes, please provide details:*

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?*

YesNo
If Yes, Please provide details*
Do you, or do you intend to export goods?*

YesNo
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. *

YesNo
Please provide details:*
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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?

YesNo

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 this cover section...*

YesNo

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 this cover section...*

YesNo

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 this cover section...*

YesNo

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 this cover section...*

YesNo

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?

YesNo
Sum Insured
Tax Audit
Cover Type
Director Name #1
Suburb
Select State
Postcode
Director Name #2
Suburb
Select State
Postcode
Director Name #3
Suburb
Select State
Postcode
Director Name #4
Suburb
Select State
Postcode
Director Name #5
Suburb
Select State
Postcode
Excess
Please indicate the excess you prefer for Tax Audit
Do you wish to provide any other information

YesNo

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 this cover section...*

YesNo

Management Liability Cover Section
Sum Insured
Management Liability
If Other, please specify limit $
Cover Option
Employee Dishonesty amount insured (optional)
Employee Dishonesty Limit Amount $
Deductible or EXCESS amount
Management Liability
Employee Dishonesty
Do you wish to provide any other information

YesNo

Review of Cover Sections Available
Business Property
Cover Section Taken ( )
Cover Section Not Taken ( )
Business Interruption
Cover Section Taken ( )
Cover Section Not Taken ( )
Theft
Cover Section Taken ( )
Cover Section Not Taken ( )
Money
Cover Section Taken ( )
Cover Section Not Taken ( )
Machinery Breakdown
Cover Section Taken ( )
Cover Section Not Taken ( )
Electronic Equipment
Cover Section Taken ( )
Cover Section Not Taken ( )
Public/Product Liability
Cover Section Taken ( )
Cover Section Not Taken ( )
Glass
Cover Section Taken ( )
Cover Section Not Taken ( )
General Property
Cover Section Taken ( )
Cover Section Not Taken ( )
Goods in Transit
Cover Section Taken ( )
Cover Section Not Taken ( )
Tax Audit
Cover Section Taken ( )
Cover Section Not Taken ( )
Management Liability
Cover Section Taken ( )
Cover Section Not Taken ( )
Review*
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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:

DayMonthYear
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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