If you have spoken to a broker in our office, note their name here so that this quote can be processed by them as they will know something about you already.

Brokers Name:

Details of the business

Type of Business (eg. butchers)

Full address

Start date of business

Construction of the business premises

Construction of Walls
Please select Brick Concrete Wood Iron Other

Construction of Floors
Please select Please select Concrete Wood Earth Other

Construction of Roof
Please select Metal Concrete Tile Other

Is (EPS) Sandwich Foam Panel construction used?
Yes    No

Year built (approx)

How are premises protected?

Sprinkler system
Yes    No

Automatic fire alarm
Yes    No

Fire hoses
Yes    No

Extinguishers
Yes    No

Deadlocks on doors
Yes    No

Bars and/or keylocks on all external windows
Yes    No

Burglar alarm system
Yes    No

If you have an alarm, which type?
Please select Please select Local Dialler Securitel Landline

Fire & Perils Insurance

Is this cover required?
Yes    No

If "Yes", please fill in the sums insured required:

Building sum insured (includes removal of debris)

Stock in trade

All other contents

Business Interruption

Is this cover required?
Yes    No

If "Yes", what is your annual turnover?

Burglary

Is this cover required?
Yes    No

If "Yes", please fill in the sums insured required:

Stock in Trade

All other Contents (excluding stock)

Money

Is this cover required?
Yes    No

If "Yes", please fill in the sums insured required:

Glass

Is this cover required?
Yes    No

If Yes, the glass will be insured for it's replacement value.

Public Liability

Is this cover required?
Yes    No

What is your annual business turnover?
$

Do you import / export goods?
Yes    No

Do you perform work away from your premises?
Yes    No

Your History

Have you or anyone to be insured under this policy:

Sustained any loss, damage, injury or liability in the last five years, whether insured or not?
Yes    No

Had insurance declined, renewal refused, terminated or special conditions imposed by any insurer?
Yes    No

Ever been declared bankrupt or gone into liquidation?
Yes     No    

Ever received any threats to life or property
Yes     No    

Had a criminal conviction or conviction pending?
Yes     No

Declaration

By submitting this Declaration, the Applicant acknowledges:
- they are authorised by all the Applicants to make this Declaration,
- the contents of this form are true and complete,
- they are under a continuing obligation to immediately inform the insurer of any change in the particulars or statements contained in this form up until the contract is entered into,

Name of person making this declaration: