property owners' insurance

Please complete this questionnaire to apply for Property Owners' Insurance.
YOUR CONTACT DETAILS
Your Name
Business Trading Name
Contact Phone Number
Fax Number
Website Address
Email Address
Postal Address
ADDITIONAL DETAILS
ABN Number
Mobile Number
Risk Address
FIRE AND PERILSDetailsClick here if you require this option. If you change your mind, click here again to close and reject this option.
BUSINESS INTERRUPTIONDetailsClick here if you require this option. If you change your mind, click here again to close and reject this option.
PLATE GLASSClick here if you require this option. If you change your mind, click here again to close and reject this option.
LIABILITYClick here if you require this option. If you change your mind, click here again to close and reject this option.
MACHINERY BREAKDOWNClick here if you require this option. If you change your mind, click here again to close and reject this option.
GENERAL QUESTIONNAIRE
1. Has any insurer declined an application from you, cancelled or refused to renew a policy of yours, required special terms to insure you, or declined or refused a claim?
If you answered Yes to this question, please give full details.

2. Have you sustained any loss or damage to property (regardless of if you made an insurance claim) or had any claims made against you in the past five years?
If you answered Yes to this question, please give full details.

3. Have you, or any person who will receive insurance protection under the proposed policy, been charged with, or convicted of, any criminal offences in the past ten years?
If you answered Yes to this question, please give full details.

4. Have you, or any person who will receive insurance protection under the proposed policy, received any threats to life or property (private or business) in the past two years?
If you answered Yes to this question, please give full details.

5. Are there any other relevant facts relating to the risk to be insured, which you should disclose to us, to enable a true assessment of your insurance questionnaire?
If you answered Yes to this question, please give full details.

6. Is any portion of the property to be insured in a state of disrepair, or poor condition?
If you answered Yes to this question, please give full details.



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IMPORTANT NOTICE

Workers Compensation Insurance is compulsory if you have employees. This cover is not provided unless such insurance is specifically shown on the schedule. Midas Insurance Brokers Insurance can arrange separate cover in those states where legislation permits. Also not covered/insured as part of this Business Insurance Package are Directors and Officers Policy and Professional Indemnity Policy. Midas Insurance Brokers Insurance can arrange separate covers for these items if necessary.

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.