Business Insurance Needs Analysis
Broker Email Address - a copy of the form will be sent to this address
*
example@example.com
Client Reference
*
Date of Enquiry
-
Day
-
Month
Year
Date
Policy Due Date
-
Day
-
Month
Year
Date
Current Insurer
Who referred client?
Sales Team
Insured Details
Insured Name
Contact Number
Format: 0000000000.
Email Address
example@example.com
Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Current Insurer
Current Excess
example@example.com
Situation of Risk
City
State
Postcode
Full Description of Business Activity
Property Details
Wall Construction
Floor Construction
Roof Construction
ESP
Please Select
Yes
No
Sprinklers
Please Select
Yes
No
Is any part of the building heritage listed?
Please Select
Yes
No
No. of Levels
Year Built
Nearest Neighbours
Occupation of Neighbors
Number of Floors
Fire & Perils Property Section
Buildings
$
Contents
$
Stock
$
Removal of Debris
$
Accidental Damage Limit
$
Business Interruption Section
Two Options: 1 or 2
1. Gross Annual Review
$
2. Gross Profit
$
Wages
$
Increased Cost of Working
$
Indemnity Period (months)
Accounting Fees
$
Burglary Section
Stock (exc, cigarettes etc)
$
Contents
$
Liquor
$
Tobacco, cigarettes etc
$
Deadlocks
Key Locks on External Windows
Key Locks
Alarm
Bars/Grills on External Windows
Money Section
Rows
$
In Transit
On Premises (business hours)
On Premises (after hours)
In Safe
In Residence
MoneMoney (combined)
Glass Section
Rows
$
Frontage (single/double)
Internal
External
Signs
General Property Section
Rows
$
Unspecified Tools of Trade
Specified Items 1
Specified Items 2
Specified Items 3
Specified Items 4
Specified Items 5
Machinery Breakdown
Machinery Breakdown - Blanket Cover
$
Details of Equipment
No. of Units
Air-Conditioning Units
No. of Units
Spa/Swimming Pool Pumps
No. of Units
Compressors, pumps, evaporators, cooling towers etc
No. of Units
Electric Doors
No. of Units
Garage Roller Doors
No. of Units
Communal Clothes Dryers/Washers:
No. of Units
Lifts/Elevators
No. of Units
Hot Water Boilers
No. of Units
Control Systems
No. of Units
Other
No. of Units
Liability Section
Public Liability
$
Products Liability
$
Goods In Care Custody and Control
$
No of Years in Business
Property Owners
Please Select
Yes
No
No. of Working Proprietors
No. of Employees
No. of Subcontractors
Wages
$
Business Annual Turnover
$
Subcontractors Annual Turnover
$
Other relevant notes
Transit Section
Sum Insured per vehicle, per annum
$
No. of Vehicles
Are cigarettes & tobacco included in sum insured?
Please Select
Yes
No
Other
Claims History
For last 5 Years
Claim #1
Insurer
Date of Loss
-
Month
-
Day
Year
Date
Details of Claim #1
Amount
Claim #2
Insurer
Date of Loss
-
Month
-
Day
Year
Date
Details of Claim #2
Amount
Claim #3
Insurer
Date of Loss
-
Month
-
Day
Year
Date
Details of Claim #3
Amount
Duty of Disclosure
Rows
Yes
No
Has the insured ever had insurance cancelled, declined, or special conditions imposed?
Has the Insured ever been charged or convicted of any criminal offence?
Are any of the units unoccupied?
Are the units used as holiday letting (short term leases)? If yes, percentage of
Has the insured ever been declared bankrupt or been placed in receivership?
Are there any hazards/defects associated with the property?
If Yes, Provide Full Details
Broker Recommendations
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