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Contact Details
Situation at Risk
Insurance Options
Additional Information
Contact Details
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Contact Person:
Email Address:
Phone Number/Mobile:
Business Details
Business Structure:
Personal
Partnership
Other
Trust
Company
Sole Trader
Superfund
Company or Insured Name:
Trading As:
ABN No.:
Registered for GST:
Yes
No
Mailing Address
Address Line 1:
Address Line 2:
Town/Suburb:
Postcode:
State:
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Situation at Risk
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Business Address
Is the business address the same as mailing address ?
Yes
No
(Cannot be a PO Box)
Address Line 1:
Address Line 2:
Town/Suburb:
Postcode:
State:
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Business Location
Please select
Industrial Area
Commercial Building
Major Shopping Centre
Small Shopping Centre
Multi-shop Strip
Standalone Building
High Rise/Multi Store Building
Other
Type of Occupancy
Please select
Rented
Owner Occupier
Owner Leased out
Other
Interested Parties (e.g. Landlord)
Yes
No
Interested Party Type
Please select
Bank/Financial Institution
Landlord
Lessor
Other
Other Interested Party Type
Name of Interested Party
How long has the business been operating?
Please select
New
1 to 2 Years
3 to 5 Years
6 to 10 Years
More 10 Years
Annual Gross Turnover
Number of Staff Full Time
Part Time
Insurance Options
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Public and product liability amount
Please select
$10,000,000
$20,000,000
General Property Cover (Electronic devices equipment away from premises)
Additional Information
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Please provide additional details of your request eg. items you want covered
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