Tools of Trade 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.
Format: 0000000000.
Current Excess
Website
Situation of Risk
City, State, Postcode
Occupation
Full Description of Business Activities
General Property Section
Tools of Trade
Unspecified items (sum insured covering all items under $2,000
Specified items over $2,000
Rows
Description
$
Item 1
Item 2
Item 3
Item 4
Item 5
Item 6
Item 7
Item 8
Item 9
Claims History
For last 5 years (include property damage, theft & fire claims)
Claim #1
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #1
Amount
Claim #2
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #2
Amount
Claim #3
Insurer
Date of Loss
-
Day
-
Month
Year
Date
Details of Claim #3
Amount
Duty of Disclosure
Rows
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
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
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