Renewal Declaration Form (Phone Only)

Do you require your insurance renewed?*

Yes, I need to renew my insurance
No, I no longer require my insurance

Name*

Company or trading name*

Do you still have the same ABN

Phone Number*

Currently I have your occupation as (ADVISE CURRENT OCCUPATION) are you doing any additional work?*

Please explain the changes*

Do you import or export?*

What are you importing, where from and % of turnover derived from imports*

If they have Public liability, do they want to change their limit?*

Based on your occupation do you require any (list appropriate insurance products relevant to occupation) and assess the client, do they give advice if yes offer PI, do they have a premises, if yes offer business insurance, etc.*

Estimated Turnover For The Next 12 Months*

Please note an increased turnover will generally increase the premium.

Do you engage in any Subcontractors?*

What do the sub-contractors do for the business?*

Estimated Payments to Sub-Contractors For The Next 12 Months*

Number of employees (including yourself or directors)*

Do you undertake any work on, or operate a business that is/has: Labour Hire, a refinery, chemical plant, petrol oil or gas production facilities or pipelines, offshore platforms, oil rigs, utilities, power station, silo's, water treatment plants, railways or railway infrastructure, airport, underground work, dams, above or below ground mine sites, trains, watercraft or any other marine or maritime exposure, aircraft, scaffolding, asbestos removal, pest control, nightclub, bar, pub, demolition, tree lopping, civil construction, cranes or work on lifts*

What of the above do you do?*

In the last 5 years have you had any criminal convictions, been bankrupt, do you have any unreported claims or incidences that you may claim against, had any insurance declined or variations imposed or anything else that may affect your insurance that we should disclose to the underwriters?*

Yes
No

We offer finance broking as one of our services. Do you require pricing on any loans or finance?*

What type of finance do you require?*

Additional Information

Renewal Declaration (Phone Only)