Main Contact – Name(s)

Email

Phone Number

Postal Address

Entity Name

ABN

Directors – Name(s)

Business Description (What do you do?)

Dangerous Goods on Site
YesNo

Building Age
0–5 years6–10 years11–20 years21-30 years31-40 years41-50 years51-60 years61-70 years71-80 years81-90 years91-100 years101-110 years

External Wall Construction

Floor Construction

Roof Construction

Fire Security
Fire ExtinguishersHose Reel24/7 Fire Station NearbyRural Fire Access OnlyTown WaterLocal Fire AlarmsMonitored AlarmsSprinkler System

Security
DeadlocksWindow Bars/ScreensLocal AlarmMonitored AlarmSecurity Fence

Highly Combustible Material (e.g. EPS or ACP)
YesNoUnsure

Asbestos Present?
YesNoUnsure

Is Plate Glass Required?

YesNo

Internal or External Glass?

BothInternalExternal

Is Sign Cover Required?

YesNo

PUBLIC LIABILITY

$5,000,000$10,000,000$20,000,000

PRODUCTS LIABILITY

$5,000,000$10,000,000$20,000,000

Do you require Tax Audit cover?

YesNo

Unspecified Tools Limit (under $3,000 per item)

Specified Tools (over $3,000)

Previous Claims Declined?
Please SelectYesNoLet's Discuss

Ever been liable for any civil offence or pecuniary penalty?
Please SelectYesNoLet's Discuss

Ever been charged or convicted of a criminal offence?
Please SelectYesNoLet's Discuss

Ever had an insurance policy cancelled, declined or terms imposed?
Please SelectYesNoLet's Discuss

Aware of circumstances which could give rise to a claim?
Please SelectYesNoLet's Discuss

Anything to Declare under Duty of Disclosure?
Please SelectYesNoLet's Discuss

let's SIMPLIFY MY INSURANCE