Business Insurance

POLICY

Proposal Date *

Policy Inception Date *

Policy Expiry Date *

BUSINESS

Business Name *

Business Establish Year *

Business Nature *

Address *

Postal Code *

Risk Location Address (If different from above) *

Risk Location Postal Code (If different from above) *

CONTACT

Person-In-Charge

Home Phone No.

Home Fax No.

Work Phone No.

Work Fax No.

Mobile No. *

Email Address *

COVERAGE

PROPERTY

Cover Type *

Building

Contents / Fixtures

Plants / Machinery

Stock

Policy Floater (Amt)

Policy Floater Description

Debris Removal

Loss of Rent

Daily Cash

Professional Fees

Deductibles *

FLOOD (OPTIONAL)

Cover Type

First Loss Limit

Any Flood Damage within last 5 years ?

Any basement ?

Deductibles

BUSINESS INTERUPTION

Cover Type

Indemnity Period

Sum Insured

ICOW Sum Insured

Floater Sum Insured

Deductibles

LIABILITY

Limit of Liability

Property owned as a landlord

No. of Employees at this location

Annual Turnover

Territorial Limits

Deductible for Liability Property Damage

DECLARATIONS

Claims Experience

Other than Work Injury Compensation claims, have you or any business partner or affiliated or subsidiary or branch or board of director in the last 3 years suffered any losses whether insured or otherwise or had any claims been made against you?

Preventative Action taken since loss occurred

Others

Have you or any business partner or affiliated or subsidiary or branch or board of director:

Had any insurer decline an application of insurance, cancel or refuse to renew a policy, impose any special condition or declined any claim?

In the last 5 years ever been declared bankrupt, or been placed in liquidation, receivership or voluntary administration?

Been convicted of or had any fines imposed for any crimes involving drugs, dishonesty, arson, theft, fraud or violence against any person or property?

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