Business Insurance Quotation Form

Business Name*
Business Address*
Street Address City Post Code
Business Occupation / Description*
If Other, Please describe*
Website*

Your Name*
First Last
Contact Phone*
Email Address*

General Information
Have you or any partner(s) or director(s) of the business (in the past five years)
made any Insurance Claim(s) for loss or damage?*
If Yes, please provide details
Insures Name Type of Loss Amount Claimed Date of Loss
had any insurance declined or cancelled, proposal/application rejected, renewal refused, claim rejected, special conditions or excess imposed by an insurer?*
Please provide
Date Insurer Reason
been convicted of a criminal offence or ever delcared bankrptcy*
Please provide*
Date Details

Details of the Business/Premises
Please provide the following details:
Building Construction
Walls Floors Roof No. of Storeys Age of Building
Number of years in this business
Are you
- the tenant
- an owner occupier
- the owner of the premesis
Is there any cooking on the Premises?*
- No
- Yes
If yes, please describe type of cooking
Do you use a Deep Fryer*
- No
- Yes
How many litres (capacity)*
Fire Extinguishers?
- No
- Yes
Fire Hoses?
- No
- Yes
Fire Sprinkler System?
- No
- Yes
Deadlocks on all External Doors?*
- Yes
- No
Bars/Grills on all External Windows?
- No
- Yes
Burglar Alarm System?*
- No
- Yes
Alarm Type*
- Local Alarm Only
- Local Alarm with Dialler
- 24 hour Monitored Alarm
Monitored By

Property Section
Sum insured : (Replacement Value)
Do you require cover for Fire & Specified Perils?*
- No
- Yes
Building - Sums Insured
Contents Including Stock - Sums Insured
Loss of Rent - Sums Insured
Removal of Debris - Sums Insured
Business Interruption Section
Sum Insured
Do you require cover for Business Interruption?*
- No
- Yes
Gross Income (Estimated for the next 12 months)*
Indemnity Period (months)
Theft Section
Sum Insured
Do you require cover for Burglary?*
- No
- Yes
All Contents (Excluding alcohol & tobacco)
Stock in Trade (Excluding alcohol & tobacco)
Stock in Trade (Including alcohol & tobacco)
Money Section
Do you require cover for Money?*
- No
- Yes
Money on premises during business hours
Please specify Sums Insured
Money on premises outside business hours
Please specify Sums Insured
Money on premises (in locked safe or strongroom)
Please specify Sums Insured
Money at private residence
Please specify Sums Insured
Do you require cover against Damage to Safe/Strongroom
Please specify amount (e.g. $2,000)
Machinery Breakdown Section
Do you require cover for breakdown of machinery, plant, boilers and pressure vessels?*
- No
- Yes
Machinery List
Type of equipment HP - Motor Size Sum Insured
Deterioration of Refrigerated Stock
Please specify Sums Insured
Electronic Equipment Section
Do you require cover for Electronic Equipment Breakdown*
- No
- Yes
Electronic Equipment
Description / Name Replacement Value
Do you require cover for Restoration of Data?
- No
- Yes
Restoration of Data (Max $30,000)
Glass Section
Do you require cover against Glass breakage*
- No
- Yes
External Glass
- Yes
- No
Please select premises type
Internal Glass
- Yes
- No
Broadform Liability Section
How many people including working partners/directors are employed in the business?
Estimated Turnover (next 12 months)

Business Insurance Quotation Form

Step 1 of 5

General Information

Details of the Business/Premises

Property Section

Business Interruption Section

Theft Section

Money Section

Machinery Breakdown Section

Electronic Equipment Section

Glass Section

Broadform Liability Section