Liability 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
Client Postal Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.
Current Excess
$
Situation of Risk
City, State & Postcode
Full description of business activities
Liability Section
Public Liability
$
Products Liability
$
Goods in care custody & control
$
Property Owners
Please Select
Yes
No
Number of Working Proprietors
Number of Employees
Number of Years in Business
Wages
$
Business Annual Turnover
$
Number of Subcontractors
Subcontractors Annual Turnover
Other Relevant Notes
Claims History
For last 5 Years
Claim #1
Insurer
Details of Claim
Amount
$
Claim #2
Insurer
Details of Claim
Amount
$
Claim #3
Insurer
Details of Claim
Amount
$
Duty of Disclosure
Yes or No
Has the insured ever had insurance cancelled, declined, or special conditions imposed?
Yes
No
Has the Insured ever been charged or convicted of any criminal offence?
Yes
No
Are any of the units unoccupied? If yes, provide details below
Yes
No
Are the units used as holiday letting (short term leases)? If yes, provide percentage of below
Yes
No
Has the insured ever been declared bankrupt or been placed in receivership?
Yes
No
Are there any hazards/defects associated with the property?
Yes
No
If Yes, Provide Full Details
Broker Recommendations
Print Form
Submit
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