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1
Business Information
2
Operational Information
When completing this form, we appreciate not everything is applicable. If this is the case on a section, please write NA. If you need help, please call our office during business hours and we will get one of our staff to complete this over the phone for you or help you with any queries you may have.
First Name
*
Last Name
*
Company name
*
Full Description of Operations & Activities
*
Estimated Annual Turnover This year
*
Limit of Indemnity
Public and Products Liability Limit Required
*
$5 Million
$10 Million
$20 Million
Do you need Public Liability Cover for Asbestos
*
Yes
No
Phone Number
*
Email
*
City / Suburb
*
Postcode
*
We offer finance broking as one of our services. Do you require pricing on any loans or finance?
*
Yes
No
What type of finance do you require?
*
Home Loan
Car Finance
Truck and Commercial Vehicle Finance
Equipment Finance
Boat or Jet Ski Finance
Personal Loan
Commercial Loan
Caravan, Camper, Motorhome or RV Finance
I Require Other Finance That Is Not Listed
Additional Comments
Duty of Disclosure
You must comply with your Duty of Disclosure when you apply for insurance with us and each time you renew or alter your cover. You have a duty of disclosure to tell us everything you know or should know, that is relevant to our decision to insure anyone under the policy, including you, and on what terms. It includes matters we specifically ask about when you apply for a policy, or renew or alter your policy, and any other matters which might affect whether we insure you and on what terms. The information you tell us can affect:
The amount of your premium and your excess, if we will insure you, if special conditions will apply to your policy.
You do not need to tell us of anything which:
Reduces the chances of you making a claim, we should know about because of the business we are in or we tell you we do not want to know
If you are unsure it is better to tell us. If you do not tell us something which you know or should know is relevant, the insurer might reduce a claim, refuse to pay a claim, cancel your policy or, if fraud is involved they can treat the policy as if it had never existed.
The duty of disclosure applies to every person or organisation insured under the policy. If you fail to comply with your duty of disclosure the insurer may be entitled to reduce their liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, they may also have the option of avoiding the contract from its beginning.
Do you understand and accept your duty of disclosure?
*
Yes I accept and understand my Duty of Disclosure
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