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Mechanic Insurance
Mechanic Form
Insured Name
ABN
Email
Phone Number
Director(s) Name(s)
Insured Address
Address Line 1
Address Line 2
City
State
Area Code
The Gross Turnover Last Financial Year in Australia
The Gross Turnover Current Financial Year in Australia
The Gross Turnover Coming Financial Year in Australia
Confirm which State/Territory You Operate In
NSW
VIC
QLD
SA
WA
TAS
NT
ACT
Do you Operate Overseas?
- Select -
Yes
No
Do You Handle Dangerous Goods?
- Select -
Yes
No
Do You Handle Asbestos?
- Select -
Yes
No
Do you Perform any Welding?
- Select -
Yes
No
Do you Import or Export?
- Select -
Yes
No
Do you assume liability or contract in additional exposure?
- Select -
Yes
No
Do all subcontractors carry their own Public & Products Liability insurance?
- Select -
Yes
No
Number of Full Time Employees
Number of Part Time or Casual Employees
Building Age
- Select -
0-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
51-55
56-60
61-65
66-70
71-75
76-80
81-85
86-90
External Wall Construction
- Select -
Timber
Asbestos
Fibro
Block
Brick
Tilt Concrete
Metal
Floor Construction
- Select -
Timber
Concrete
Other
Roof Construction
- Select -
Metal
Colorbond
Tile
Concrete
Asbestos
Fire Security
Fire Extinguishers
Hose Reel
24/7 Fire Station Nearby
Rural Fire Access Only
Town Water
Local Fire Alarms
Monitored Alarms
Monitored Alarms
Security
Deadlocks
Window Bars/Screens
Local Alarm
Monitored Alarm
Security Fence
Highly Combustible Material (e.g. EPS or ACP)
Yes
No
Unsure
Asbestos Present
Yes
No
Unsure
Is Property Damage Required?
Yes
No
PROPERTY DAMAGE - Building Sum Insured: $
PROPERTY DAMAGE - Contents Sum Insured: $
PROPERTY DAMAGE - Stock Sum Insured: $
Is Business Interruption Required?
Yes
No
BUSINESS INTERRUPTION - Gross Turnover (excluding GST): $
BUSINESS INTERRUPTION - Total Purchases: $
BUSINESS INTERRUPTION - Total Wages: $
Is Plate Glass Required?
Yes
No
PLATE GLASS - Options
Internal
External
Both
Is Machinery Breakdown Required?
Yes
No
Air-Conditioners: $
Fridges/Freezers: $
Other Machinery: $
Is Public and Products Liabiity Required?
Yes
No
PUBLIC LIABILITY - Limit of Liability
- Select -
$5,000,000
$10,000,000
$20,000,000
$50,000,000
PRODUCTS LIABILITY - Limit of Liability
- Select -
$5,000,000
$10,000,000
$20,000,000
$50,000,000
PRODUCTS LIABILITY - Care, Custody and Control
- Select -
$250,000
$500,000
$1,000,000
Is Tax Audit Required
Yes
No
TAX AUDIT
- Select -
$10,000
$20,000
Is Accident & Sickness Required?
Yes
No
ACCIDENT & SICKNESS
- Select -
Accident & Sickness
Accident Only
Sickness Only
Gross Weekly Wage
Is Tool & Equipment Required?
Yes
No
TOOL & EQUIPMENT - Unspecified Tools Limit (under $3,000 per item)
Would you like to insure a vehicle/s?
Yes
No
COMPANY WORK VEHICLE/S - include Registration all Accessories and Modifcations
COURTESY VEHICLE
Drivers including Date of Birth
Finance
If adding a vehicle - will this vehicle/s be used for Driver Education, Racing, Courier/Delivery, Hire Car, Taxi, Uber, Courtesy , Removalist
- Select -
Yes
No
If adding a vehicle - has any drivers lost licence or been suspended
- Select -
Yes
No
If adding a vehicle - has any drivers had any traffic convictions
- Select -
Yes
No
Would You Like To Cover Customer Vehicles
- Select -
$50,000
$75,000
$100,000
$200,000
$500,000
Previous Claims Declined?
- Select -
Yes
No
Ever been liable for any civil offence or pecuniary penalty?
- Select -
Yes
No
Ever been charged or convicted of a criminal offence?
- Select -
Yes
No
Ever had an insurance policy cancelled, declined or terms imposed?
- Select -
Yes
No
Aware of circumstances which could give rise to a claim?
- Select -
Yes
No
Anything to Declare under Duty of Disclosure?
- Select -
Yes
No
Additional Information about you or the property
Submit Form
