Commercial Property Proposal 1 Proposer Details 2 General Questions 3 Property Situations 4 Fire Events & BI 5 Covers - Security - Declaration 1) Your Details Name of Insured - including all subsidiary companies to be insured Australian Business Number ABN Additional ABN - if applicable Trading Name Names of all Principals - Partners - Directors Postal Address Postcode Contact Name Email Phone Fax Main activities of your business 2) Interested Parties Full name(s) of interested parties - eg mortgagee - finance company - lessor Nature of interest 3) Period of Insurance Requested From (4 pm) To (4 pm) Cover is not in force until the insurer has accepted the proposal. Previous Next 4) General Questions If more than one person, director, company or entity comprises the insured, all questions apply to all persons. (a) Any insurer declined, cancelled or refused to renew, or imposed special terms YesNo (b) Business operating for less than 12 months YesNo (c) Any portion of the property in disrepair or poor condition YesNo (d) Operating without insurance for more than 3 months YesNo (e) Charged with or convicted of a criminal offence in the past 10 years YesNo (f) Declared bankrupt or put into receivership or liquidation YesNo (g) Any other relevant facts to disclose YesNo If Yes to any of the above, provide full details (h) Is the business trading profitably YesNo (i) Estimated Turnover (j) Estimated number of Employees (k) Financial accounts audited at regular periods YesNo (l) Complete record kept of stock received and sold YesNo If No, explain how a loss could be quantified and valued Loss or Damage History - last 5 years Date of Loss Cause and Description Amount $ Applicable Excess $ Insurer Steps taken to prevent a recurrence Previous Next 5) Situation(s) of Property to be Insured Situation 1 Situation 2 Situation 3 6) Property Details Occupancy and construction details for each situation. Situation 1 Situation 2 Situation 3 Occupancy Construction Walls Frame Roof Floors - Ground Floors - Other No. of storeys Approx. age Any Asbestos in the structure or installation of the premises YesNo If Yes, detail the areas Any EPS panelling in the structure or installation YesNo If Yes, provide details and floor ratio percent Floor ratio percent Aluminium Composite Panels (ACP) installed to exterior YesNo If Yes, provide details of the panelling Previous Next 7) Fire and Defined Events (a) Insuring buildings and business contents for indemnity value only YesNo If No you will be insured for reinstatement or replacement value. Enter sums below. (b) Sums Insured at the Situation Situation 1 Situation 2 Situation 3 Building including fixtures and fittings $ $ $ Plant - Machinery - Leasehold improvements - other Trade Contents $ $ $ Stock - Merchandise $ $ $ Removal of Debris $ $ $ Extra Cost of Reinstatement $ $ $ Other (Please specify) $ $ $ Total sum insured $ $ $ (c) Accidental Damage Situation 1 Situation 2 Situation 3 Sum insured $ $ $ 8) Business Interruption Situation 1 Situation 2 Situation 3 Indemnity Period Insured - Gross Profit or Gross Revenue $ $ $ Payroll 100 percent (where insured separately) $ $ $ Payroll (Dual Basis) $ $ $ Additional increased cost of working $ $ $ Professional fees and claims preparation costs $ $ $ Loss of Rent for months $ $ $ Other (Please specify) $ $ $ Total sum insured $ $ $ Dual Payroll Limits - Initial period percent for weeks Dual Payroll Limits - Remainder percent for weeks Dual Payroll Limits - Consolidation period weeks Previous Next 9) Theft - Burglary Cover Situation 1 Situation 2 Situation 3 Stock (excluding tobacco products) $ $ $ Tobacco - Cigars - Cigarettes $ $ $ Trade Contents (other than Stock in Trade) $ $ $ Theft without forcible and violent entry $ $ $ Other (Please specify) $ $ $ Total sum insured $ $ $ 10) Money Cover Situation 1 Situation 2 Situation 3 Money in Transit $ $ $ Money on the Premises - During Business Hours $ $ $ Money on the Premises - Outside Business Hours (not in safe) $ $ $ In locked safe or strongroom $ $ $ Money in Private Residence $ $ $ Damage to Safes or Strongroom $ $ $ Total sum insured $ $ $ If cover is required in Safe or Strongroom, provide details Make Model Approx. Age Size Is the Safe or Strong Room Door Torch and Drill Resistant quality (TDR) YesNo 11) Accidental Breakage of Glass Situation 1 Situation 2 Situation 3 External Glass YesNo YesNo YesNo Internal Glass YesNo YesNo YesNo Cost of temporary shuttering $ $ $ Cost of sign writing or ornamentation on glass $ $ $ Damage to stock from breakage of glass $ $ $ 12) Fire Protection Situation 1 Situation 2 Situation 3 Are the premises sprinkler protected YesNo YesNo YesNo If Yes, maintained under a service contract YesNo YesNo YesNo What type of supply SingleDual SingleDual SingleDual Fire hydrants located throughout the premises YesNo YesNo YesNo Fire blankets YesNo YesNo YesNo Hoses and reels YesNo YesNo YesNo Fire extinguishers YesNo YesNo YesNo Hard wired thermal - smoke detectors YesNo YesNo YesNo Area coverage percent Fire alarm installed YesNo YesNo YesNo If Yes, Local - Connected to Fire Brigade - Connected to Security Company Name of Monitoring Company Area Coverage percent Are premises on town water supply YesNo YesNo YesNo If No, provide full details of water source Distance km to nearest Fire Brigade Is Fire Brigade permanently staffed YesNo YesNo YesNo If Yes, how are they protected 13) Security Situation 1 Situation 2 Situation 3 All perimeter doors deadlocked YesNo YesNo YesNo All perimeter windows protected by bars or grills YesNo YesNo YesNo Any skylights in the roof YesNo YesNo YesNo Random visit Security night patrols YesNo YesNo YesNo PIR - Motion Detectors YesNo YesNo YesNo Local sounding alarm only YesNo YesNo YesNo Alarm connected to monitoring company YesNo YesNo YesNo If Yes, what type of system GPRSDedicated LineDigital Dialler GPRSDedicated LineDigital Dialler GPRSDedicated LineDigital Dialler Who is notified when the alarm is activated ClientPatrolPolice ClientPatrolPolice ClientPatrolPolice Monitoring company has access to investigate alarm activation YesNo YesNo YesNo Other security measures 14) Cooking Refer to the Cooking Questionnaire at www.penunderwriting.com.au/property-policy-proposals 15) Woodworking Refer to the Woodworking Questionnaire at www.penunderwriting.com.au/property-policy-proposals Declaration I declare that: I am authorised by each of the Applicant(s) to sign this Proposal. The statements in this Proposal are true and complete and no material information has been withheld. I have read and understood the Important Notices accompanying this Proposal. I have diligently made all necessary enquiries in order to comply with the duty of disclosure. I have read the Pen Underwriting Privacy Statement on this Proposal and consent to the use, disclosure and obtaining of personal information for the purposes shown in the Privacy Statement. Where I have provided information about another individual, that individual has been made aware of that fact and of the Privacy Statement. I acknowledge Pen Underwriting relies on the information and representations in this Proposal. Except where indicated to the contrary, any statement made in this Proposal will be treated as a statement made by all persons to be insured. I will notify Pen Underwriting of any material alteration prior to inception of the proposed insurance. I understand that no insurance is in place until acceptance is confirmed by Pen Underwriting. Signature Date Full Name Title - Position Previous Next
