RWTA Member Underwriting Information
Requested by Benjamin and Benjamin Insurance Group
Contact Name
*
First Name
Last Name
Business Name
*
Company Name
*
Contact Phone
*
Contact Email
*
example@example.com
Physical address of each location to be insured
Property/ISR insurance
Rows
Base premium
Underwriter Fee-(if charged)
)
Fire Services Levy
(if applicable)
GST
Stamp Duty
Broker Fee
Total Paid
2023
2022
2021
Claims information - Property/ISR
Rows
Please Declare all claims in each in each calander year
2023
2022
2021
Liability Insurance
Rows
Base premium
Underwriter Fee - (if charged)
GST
Stamp Duty
Broker Fee
Total Paid
2023
2022
2021
Claims information - Liability Insurance
Rows
Please Declare all claims in each in each calander year
2023
2022
2021
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Signature
*
Submit
Should be Empty: