trades pack insurance questionnaire

Please complete this questionnaire to apply for our Trades Pack 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
Describe the business carried out
LIABILITY
Public liability
Products liability
Goods in physical and legal control
Do you export?
If you answer Yes to this question, please list the countries.

Do you import?
If you answer Yes to this question, please list the countries.

What is your annual turnover? $ 
State the products you manufacturer, assemble, supply and/or re-pack:
Do you subcontract?
What is the total number of proprietors and partners?
What is the total number of staff?
GENERAL PROPERTY
Cover for Accidental Damage and Fire?
Specified Items Sum Insured
1. $ 
2. $ 
3. $ 
4. $ 
5. $ 
Total Sum Insured $ 
Restricted Cover?
1. Fire (whether resulting from an explosion or otherwise)
2. Collision and/or overturning of the conveying vehicle; and
3. Flood.
Situation of the Property Insured - Anywhere in Australia
Cover Required?
Description of Item Sum Insured
Unspecified items or tools relating to your trade or profession (Excludes mobile phones, photographic equpiment and computer equipment) $ 
Specified Item Sum Insured
1. $ 
2. $ 
3. $ 
4. $ 
5. $ 
Subtotal Sum Insured $ 
Stock in Trade (including Customers' Goods and items held in trust or on commission) $ 
Office Contents $ 
Total Sum Insured $ 
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.

VEHICLE DETAILS
Address where vehicle is kept
Vehicle type
Vehicle make
Vehicle model
Year of manufacture
Registration number
Engine number
No. of cylinders
Engine size (litres)
Purchase price $ 
Currently insured for $ 
Gross weight
Type of goods carrying
Distance travelling from base
Modifications/accessories
If Yes, please provide details and values
VEHICLE FINANCING DETAILS
Is the vehicle under finance?
If under finance, what is the monthly payments? $ 
POLICY REQUIREMENTS
Is the vehicle insured?
YOUR DETAILS
Name of main driver
Date of birth   Year 
Years licenced in Australia
Years driving this vehicle type
Your rating   or   %
Your current insurer
Due date of policy renewal   Year 
ADDITIONAL DRIVER DETAILS
Name of driver
Date of birth   Year 
Years licenced in Australia
Years driving this vehicle type
INSURANCE HISTORY
Have any of the insured drivers ever:
Had a motor accident
Had a vehicle stolen or burnt
Made any motor vehicle insurance claim
Had a traffic infringement, conviction or prosecution
Had driving or motor cycle licence cancelled, suspended or not renewed
Suffer from any physical or mental disability or medical condition which could affect their driving performance
If Yes for any of the above please give full details


Enter Validation Code
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.