Freight Pack Insurance

Please complete this questionnaire to apply for Freight Pack Insurance.

YOUR CONTACT DETAILS

Name of Proposer
Business Trading Name
Contact Person
Contact Phone Number
Fax Number
Website Address
Email Address
Postal Address

ADDITIONAL DETAILS

ABN Number
Mobile Number
Details of Situation
Situation of Risk
Occupied As
If Office and Warehouse, do you store any hazardous goods?
If Yes, please provide detail
size of premises (sq m)
Construction of Situation(s)
Wall construction
Floor construction
Roof construction
Age of buildings
Protection
Sprinkler system
Fire Extinguishers	Type: Qty:
Service Agreement?
Operative?
Security
Alarm System
Type of Alarm
Service Agreement Operative?

PROPERTY

BUSINESS INTERRUPTION

THEFT OR PROPERTY

MONEY

GLASS

LIABILITY

EMPLOYEE DISHONESTY

MACHINERY BREAKDOWN

COMPUTER SYSTEMS / ELECTRONIC EQUIPMENT

BUSINESS INTERRUPTION

GENERAL PROPERTY

TAXATION INVESTIGATION

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DECLARATION

By Pressing the 'Send Questionnaire' button, we declare that to the best of my/our knowledge and belief the above statements and particulars are true and correct.

SECTION 1: PROPERTY	Sum Insured
Buildings	$
Contents (Excluding Stock)	$
Rent	Months: $
Stock in Trade	$
Other	$
Removal of Debris	$
Rewriting of Records	$
Accidental Damage	$

SECTION 2: BUSINESS INTERRUPTION	Sum Insured
Note: Gross income and Weekly income cannot both be taken.
Indemnity Period (Months)
Gross Income	$
Uninsured Working Expenses
Pay Roll	% for wks % for remainder Consolidated Period weeks $
Increased cost of working	$
Books debts	$
Gross rental	Indemnity Period (months): $
Weekly Income	Weekly Amount Insured: $ multiplied by Indemnity Period (Weeks): equals sum insured: $
Accountants Fees	$

SECTION 3: THEFT OR PROPERTY (PART A)	Sum Insured
Tobacco, Cigars and Cigarettes	$
Stock (excludes tobacco, cigars and cigarettes)	$
Contents (other than specified items listed below)	$
Total Contents (incl. stock, excl. tobacco, cigars and cigarettes)	$
Rewriting of documents (indicate limit any one situation)	$
Specified items (as listed below)	$
Specified Items List

SECTION 3: MONEY (PART B)	Sum Insured
Whilst in transit, in bank night safe or in automatic teller machine	$
On premises during normal business hours	$
On premises outside normal business hours	$
Whilst contained in a securely locked safe or strongroom on the premises	$
Private residences	$
Damage to safes and strongrooms - above Policy Limit Money	$

SECTION 4: GLASS	Sum Insured
Internal - Replacement Value	$
External - Replacement Value	$
Specified Glass	$

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Freight Pack Insurance

SECTION 5: LIABILITY	Sum Insured
Part A: Public Liability - Limit of indemnity	$
Part B: Products Liability - Limit of indemnity	$
Property in physical or legal control

SECTION 6: EMPLOYEE DISHONESTY	Sum Insured
Any one employee or group of employees	$
Any one period of insurance	$
Maximum amount of cash on premises	$
Number of locations

SECTION 7: MACHINERY	Sum Insured
Breakdown - Limit any event	$
Pressure Equipment - Explosion and Collapse	$
Property to be insured
1.	$
2.	$

SECTION 8: PART A - COMPUTER SYSTEMS / ELECTRONIC EQUIPMENT
Details of Equipment	Sum Insured
1.	$
2.	$
3.	$

SECTION 8: PART B - BUSINESS INTERRUPTION	Sum Insured
Increased Cost of Working	Indemnity Period (months): $
Gross Income	Indemnity Period (months): $
Reinstatement of Data	$

SECTION 9: GENERAL PROPERTY
Details of Property	Sum Insured
1.	$
2.	$
3.	$
4.	$

SECTION 10: TAXATION INVESTIGATION	Sum Insured
Sum Insured for Taxation Investigation Costs