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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:
Company
Other
Partnership
Personal
Sole Trader
Superfund
Trust
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
Commercial Unit
Standalone Building
High Rise Building (3+ Storeys)
Industrial Area
Strip Mall
Shopping Centre with External Frontage
Kiosk at Shopping Centre
Fully Enclosed Shop within a Major Shopping Centre
Residential Building
Other
Type of Occupancy
Please select
Owner Occupied
Rented by the Insured
Rented to Tenants
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 Venture
Less than 1 year
1 to 2 years
2 to 3 years
3 to 4 years
4 to 5 years
Over 5 years
Annual Gross Turnover
Full Time Staff
Part Time Staff
Insurance Options
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Public and product liability amount
Please select
$10,000,000
$20,000,000
Unspecified Portable Valuables / General Property Sum Insured (Electronic Items, Tools etc) - a sub-limit any one item may apply
Additional Information
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Please provide additional details of your request eg. items you want covered
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