Business Package 1 Business details 2 General Business Liability 3 Property Details 4 Other Optional Coverages 5 Insurance Claims History Introduction Please answer all questions in this proposal form. Blanks and/or dashes, or answers “known to underwriters or brokers” or “N/A” are not acceptable and will delay processing of this application. If there is insufficient room to complete a question, please attach a signed & dated addendum. Any documents attached to this document form part of this application. Where appropriate, please tick the yes or no box which best indicates your reply. If you have any questions whilst completing this insurance proposal form, please let us know. Thank you. Primary Contact First Name Last Name Job Title / Position Email Phone Mobile Primary Insured Insured Name Trading Name(s) Address Address 2 City State —Please choose an option—ACTNSWNTQLDSATASVICWA Postcode ABN Year Business Established Exempt from Stamp Duty? NoYes If yes, what is your exemption number? What is your Business Website Address? Additional Insureds Are there any other entities or individuals to be insured under this policy? NoYes Additional Insured 1 Insured Name Trading Name(s) ABN Year Business Established Registered for GST? NoYes Input Tax Credit (ITC) % Additional Insured 2 Insured Name Trading Name(s) ABN Year Business Established Registered for GST? NoYes Input Tax Credit (ITC) % Business Details Description of Business Activities Estimated turnover for the next 12 months Estimated wages for the next 12 months Number of full time employees Number of part time employees Interested Parties Current Cover Do you currently have Business Pack insurance cover in place? NoYes Name of Insurer Policy Limits Excesses Expiry Date of Policy Upload a copy of your current policy Required Period of Cover Start Date End Date Previous Next General Business Liability Is cover required for Public and Products Liability? NoYes Do you require cover as the property owner only? NoYes Limits cover to the property owner’s public liability (not the operating business). Do you engage subcontractors? NoYes Do you ensure they have their own Liability and Workers Compensation policies in place? NoYes Estimated amount to be paid to subcontractors (next 12 months) Do you engage labour hire or hired-in labour? NoYes Estimated amount to be paid to labour hire (next 12 months) Do you import any goods? NoYes Does the business import any of the following: medical/pharmaceutical/veterinary products (incl. medicines, instruments/equipment)cured and/or fermented meatgases or air under pressureproducts designed or clearly intended for children up to 4 years of ageany aircraft and/or aircraft componentstoys, bicycles/tricycles and/or playground equipment (all ages)firearms, fireworks, ammunition, explosives and/or their component partsmechanised sporting/gymnasium equipmentself-propelled vehicles/rolling stock and/or critical componentshydraulic lifting equipmenttobacco and/or vaping productsany food products from China, Hong Kong, Taiwan or Indiablood and/or blood productsany vitamins/supplementschemicals (incl. cosmetics, pesticides, insecticides, industrial chemicals)safety and/or personal protective equipmentstockfeedany product subject to an Australian mandatory safety standard / not compliant with Australian standards Please confirm what products you import, the country of origin and what % (approx) of your turnover applies to each Do you intend to use, store or handle any hazardous substances? NoYes If yes, provide details of the hazardous waste and method of discharge Do you discharge hazardous waste material into the atmosphere, sewer or elsewhere? NoYes If yes, please provide further details of the hazardous waste and method of discharge Do you hire out equipment and/or staff? NoYes Is there a Hire Agreement with a disclaimer or legal waiver signed before hiring? NoYes Is all equipment checked and maintained after each hire? NoYes List each type of equipment you hire out + approx turnover ($) for each Does the business hire out any of the following: medical or surgical equipmentelevated work platforms/scaffoldingwatercraftmotorised cutting/sawing equipmentjumping castlesself-propelled vehicles/plant without an operator Annual payments received from hiring out your staff to others Have you or any directors/officers entered into any Hold Harmless agreements? NoYes Please provide details In which state(s) does the business generate turnover/income? ACTNSWVICQLDSAWATASNTInternational Limits of Liability and Excess/Deductible Public Liability (any one claim) / Products Liability (any one claim & in the aggregate) —Please choose an option—$5,000,000$10,000,000$20,000,000$30,000,000$50,000,000Other Limit of cover for Property of others in your Care, Custody or Control —Please choose an option—$100,000$200,000$250,000$500,000$1,000,000Other Preferred excess/deductible for Personal Injury Claims Preferred excess/deductible for Property Damage Claims Do you require any of the following additional extensions of cover? Cover for Market Stalls or Pop up StallsTreatment Risk (Hairdressers, Beauticians)Treatment Risk (Allied Health)Treatment Risk for Animals (Vets)Errors and Omissions CoverVictorian Plumbers - Consumer Protection LiabilityQueensland Electricians - Consumer Protection LiabilityOther If 'Other', please describe Previous Next Business Premises / Portable Equipment Do you require cover for a business premise or portable equipment? NoYes Property Details Situation 1 Year Built Year Last Rewired Number of Levels you own or occupy (including basement) Number of Buildings On Site Is this location Heritage Listed (either Local Interest, State, or Federal Listing)? NoYes Do you rent or own the Premises? —Please choose an option—RentOwn Where are the premises located? Construction Details Ground Floor Construction Material(s) Concrete (such as a concrete slab)Floating floor (on a concrete slab)Timber / WoodIron / SteelBrickOther External Wall Construction Material(s) Concrete / StoneConcrete (Tilt Slab)Concrete (Blocks)Iron / Steel / Aluminium on a Steel FrameIron / Steel / Aluminium on a Timber FrameMetal (other)Brick VeneerDouble BrickMasonry, including Rendered SurfacesGlassPolystyreneSandwich Panel (with EPS or FR-EPS core)Sandwich Panel (with other foam core)Sandwich Panel (with certified fire compliant core - certificate required)Sandwich Panel (with no core material)Other Roof Construction Material(s) ConcreteMasonryTile(s) / SlateAsbestosIron / Steel / Aluminium on a Steel FrameIron / Steel / Aluminium on a Timber FrameExpanded Polystyrene (EPS)Other Sandwich Panel SystemWoodGlassOther Does the premises contain any asbestos? NoYes Does the premises have any EPS (Expanded Polystyrene) or other flammable insulation? NoYes If you are able to attach a photo of the EPS or flammable insulation please do so here Upload or drag files here. If known, please tell us what the core of the Sandwich Panels or Insulation is made from (e.g., EPS, XPS, FR-EPS) What percentage of the floor area has EPS or another flammable insulation material? Security Protection Details Does the premises have a burglar alarm? NoYes Is the alarm monitored by a security company? NoYes What type of monitored alarm is in place? —Please choose an option—Class 2 e.g. Digital DiallerDual Path GPRS/IP MonitoringBack-to-Base MonitoredLocal Only (not monitored)Other Does the premises have any of the following: DeadlocksKeyed Window LocksBars on WindowsExternal LightingSecurity FencingBollardsRoller ShuttersCCTVAfter Hours WatchmanSecurity PatrolsElectronic Key Pad / Swipe Card Access Fire Protection Details Does the premise have a connection to Town Water Supply? NoYes Does the premises have sprinklers? NoYes Water supply —Please choose an option—Single Supply (there is only town water)Dual SupplyOther 100% coverage NoYes Conforms to Australian Standards NoYes Does the premises have any of the following: Fire ExtinguishersHose ReelsFire BlanketsHeat DetectorsSmoke Detectors - MonitoredSmoke Detectors - Non-monitoredFire AlarmMonitored Base AlarmFire Doors Proximity to Fire Brigade How frequently do you have your fire protection equipment serviced? —Please choose an option—MonthlyQuarterlyHalf-yearlyAnnuallyOther Do you generate and store any waste materials NoYes If you have bins or cardboard boxes that you put waste into, please select Yes. Is waste (incl any bins or recycling bags) kept away from the walls of the building? Cafe, Restaurant, Bar, or Commercial Cooking - Additional Questions Does the premise contain a cafe, restaurant or bar? —Please choose an option—No, None of theseCafeRestaurantBarCommercial kitchen / cooking (e.g., deep fryers, chargrill)Other Are there wet chemical and/or dry chemical B(E) fire extinguishers and fire blankets in place? NoYes In seats, what is the capacity of your cafe or restaurant? Less than 100 seats100 or more seating capacity Are you authorised by your local government authority to place outdoor furniture (comprising tables and chairs) and/or signs in a public place such as a footpath? NoYes Are there any deep fryers? NoYes What is the total capacity in litres for all deep fryers / vats at the premise? Are all deep fryers thermostatically controlled and fitted with an automatic over temperature cut out device? NoYes Do all deep fryers have an automatic supression system fitted? NoYes Is there wok cooking? NoYes Does the wok cooking equipment have a flame failure automatic cut off module and exhaust system NoYes Does the wok cooking equipment have its own water cooling and filling system? NoYes Is there a (or multiple) wood fired oven(s)? NoYes Is there any other method of wood fire / charcoal / firestone cooking? NoYes How often are all rangehoods and ducts cleaned? How often are all rangehood filters / extraction filters cleaned? Photos of your business If you are on your mobile phone, you can add photos of your business premise to help us better see and understand what you would like insured. If an area isn’t applicable, you can leave that section blank. You can use your mobile phone camera or photo library to attach images here. Would you like to add photos of your business? YesNo Photo of the front of your building (External) Uploador drag files here. Photo of the left hand side of your building (External) Uploador drag files here. Photo of the Right hand side of your building (External) Uploador drag files here. Photo of the waste storage area (External) Uploador drag files here. Photo of your car park / customer parking area (External) Uploador drag files here. Additional External Photos Uploador drag files here. Photo of your reception or showroom (Internal) Uploador drag files here. Additional Internal Photos (Internal) Uploador drag files here. Photo of your Fire Safety Equipment service tag or service logs showing the latest service date Uploador drag files here. Please provide a photo of your cooking area Uploador drag files here. Cover required at this situation Material Damage This covers damage to your business premise for Fire, Storm, and other defined perils. Sums insured should be sufficient to rebuild/repair and/or replace items as new. Building Sum Insured Contents/Plant/Equipment Sum Insured Stock Sum Insured Is Flood Cover required? NoYes Preferred Excess for Material Damage Business Interruption Covers loss of income or extra expenses following damage at the insured location. If you’re a small/family business and the business is your main source of income, consider this cover. Is Business Interruption Cover required? NoYes Type of Cover —Please choose an option—Gross ProfitAnnual RevenueGross RentalsIncreased Cost of Working (ICOW) onlyOther Business Interruption Sum Insured Is 100% Payroll included in the Sum Insured? NoYes Claims Preparation Costs Sum Insured Indemnity Period (months) If unsure, consider how long it may take to set up a new premise elsewhere, recommission equipment, order stock, and start operating again. Add at least 6 months to allow lost income recovery. Property owners should consider tenant replacement times — minimum 24 months recommended. Additional Increased Cost of Working Sum Insured Major Customer or Supplier Cover Do you want to insure a Major Customer or Major Supplier’s premise in case damage impacts your income? NoYes Customer or Supplier 1 Are they a customer or supplier? CustomerSupplier What is their name? Address of your customer or supplier Country —Please choose an option—AustraliaNew ZealandOther What type of goods do you supply to them? As a percentage (%), what portion of your turnover/total sales would be affected? Customer or Supplier 2 Are they a customer or supplier? CustomerSupplier What is their name? Address of your customer or supplier Country —Please choose an option—AustraliaNew ZealandOther What type of goods do you supply to them? As a percentage (%), what portion of your turnover/total sales would be affected? Burglary and Theft Is Burglary and Theft Cover required? NoYes Theft of Contents & Stock Sum Insured Theft in the Open Air Sum Insured Theft of Cigarettes Sum Insured Theft of Alcohol Sum Insured Damage to Rented Premises Sum Insured Theft of Customer's Goods Theft Without Forcible and Violent Entry Sum Insured Do you require cover for company goods or stock by employees? NoYes Preferred Excess/Deductible for Theft Money / Cash Cover for money/cash at the premises, in transit, at an employee’s home, or in authorised overnight storage. Is cover for money, cash, or securities required? NoYes Do you require separate limits for on-site, in transit, after hours, etc.? YesNo If not specified, we’ll treat the Money Sum Insured as a blanket limit across money/cash cover. Select “Yes” if you need specific sub-limits; we will contact you to discuss. Money Sum Insured Preferred Excess/Deductible for Money Do you require cover for theft of money by employees? NoYes Glass This cover may be required in your lease agreement if you are a renter. It provides cover for more than just windows — also external signage, fit-out glass, or ceramics within the premises. Is Glass Cover required? NoYes Type of Cover InternalExternalInternal & External Separate Sum Insured for External Signs Preferred Excess/Deductible for Glass General Property This cover applies to portable business property, such as tools, equipment, or stock, while away from the premises. Is General Property Cover required for equipment or stock away from the premise? NoYes Unspecified Business Items Description Unspecified Business Items Sum Insured Do any Business Items need to be specified? NoYes Specified Business Items Item 1 × Description Sum Insured Item 2 × Description Sum Insured Item 3 × Description Sum Insured Item 4 × Description Sum Insured Item 5 × Description Sum Insured + Add Item Tip: Include make/model/serial and replacement value (incl. GST). General Property Excess Previous Next Other optional coverages for your business The following covers may not be offered by all insurers though may be required by your business. If you select any options below, we may contact you if we require any additional information. Additional cover required Professional IndemnityCyber Crime & Cyber Liability InsuranceManagement (incl Directors) LiabilityEmployee DishonestyTax AuditBreakdown of Motors and Mechanical PlantBreakdown of Electronic ItemsBusiness Travel InsuranceBusiness or Commercial Motor VehiclesMobile plant or Machinery incl Forklifts or EWPsMarine Transit Insurance (Stock in Transit)Other If ‘Other’, please specify Previous Next Insurance Claims History Have you had any claims during the past five (5) years, whether you were at fault or not, relating to the proposed insurance? Claims in the past 5 years? NoYes Claim 1 Date of Claim Brief Description of Claim Insurer Amount of Claim What actions have you taken to prevent a similar issue from occurring again? Claim 2 Date of Claim Brief Description of Claim Insurer Amount of Claim What actions have you taken to prevent a similar issue from occurring again? Upload Claims History Document Are you aware of any circumstances or incidents which may give rise to a claim? NoYes Please provide details Additional Information Please provide any additional information you would like to share with us relating to the proposed insurance. Additional Information Attachments Upload or drag files here. Important Information Cooling Off If you are not completely satisfied with your policy, you may cancel it by notifying us in writing within 30 days of cover having commenced. You will receive a refund of the amount you have paid unless something has occurred for which a claim may become payable under the policy. Confirming Transactions You may contact us, in writing (which is always required if you are advising cancellation) or by phone, to confirm any transaction under your policy. Any transaction will be documented by us as quickly as possible. Code of Practice A self-regulatory Code of Practice exists for the general insurance industry, designed to raise overall standards. We have adopted the Code, details of which can be obtained from your insurance broker or our office. Complaints If you do not agree with any decision we make in relation to your insurance, please write to us stating what you disagree with and why. We will then either resolve or attempt to resolve your complaint immediately or refer the matter to our Internal Dispute Resolution Committee (IDRC). If you are not satisfied with a claim decision by the IDRC, the matter may be referred to the Australian Financial Complaints Authority (AFCA) if it falls within their jurisdiction. Privacy We respect your privacy and comply with the Privacy Act and the National Principles. A copy of our Privacy policy is available upon request or on our website. Duty of Disclosure Duty to not misrepresent Your duty when you apply for insurance Before you enter into an insurance contract, you have a duty to not misrepresent under the Insurance Contracts Act 1984. By law, you must take reasonable care not to make a misrepresentation. This means giving us true, complete and accurate answers to our questions, including where you provide information on someone else’s behalf. We use your answers to decide whether to insure you and on what terms. If you do not tell us something If any of your answers are misleading, incomplete, inaccurate or fraudulent we may reduce or not pay a claim, cancel your policy or treat it as if it never existed. Have you or any partner, principal, shareholder or director of the business ever been / had: Insurance declined, cancelled, renewal refused or special conditions imposed by an insurer? NoYes Declared bankrupt? NoYes Involved in a company or business which became insolvent or subject to any form of insolvency or voluntary administration (e.g. liquidation or receivership)? NoYes Convicted of any criminal offence within the past 5 years (other than minor traffic convictions)? NoYes Liable for any civil offence or pecuniary penalty exceeding $5,000? NoYes Are there any other matters that you should or would like to disclose? NoYes Declaration I hereby declare that: My attention has been drawn to the important notices accompanying this Application form and I have read these notices carefully and acknowledge my understanding of their content by my signature below. The above statements are true, and I have not suppressed or mis-stated any facts and should any information given by me alter between the date of this Application form and the inception date of the insurance to which this Application relates I shall give immediate notice thereof. I authorise you to collect or disclose any personal information relating to this insurance to/from any other insurers or insurance reference service. Where I have provided information about another individual (for example, an employee, or client), I declare that the individual has been or will be made aware of that fact and the section in the Policy on “The way we handle your personal information”. I also confirm that the undersigned is authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this Application form and I complete this Application form on their behalf. 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