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retail insurance
Please complete this questionnaire to apply for Retail 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
DETAILS OF PROPERTY
Wall construction
Please make your selection.
Brick
Concrete
Iron
Wood
Other
Floor construction
Please make your selection.
Concrete
Wood
Other
Roof construction
Please make your selection.
Iron
Concrete
Other
Age of buildings
If over 25 years, date building was last re-wired
size of premises (sq m)
Fire Extinguishers
Please make your selection.
Yes
No
Type:
Qty:
Fire Hose Reel
Please make your selection.
Yes
No
Qty:
Sprinkler system
Please make your selection.
Yes
No
Alarm system
Please make your selection.
None
Local
Landline
Monitored
Deadlocks on external doors
Please make your selection.
Yes
No
Windows barred
Please make your selection.
Yes
No
FIRE AND PERILS
Buildings
$
Contents
$
Stock in Trade
$
Removal of Debris
$
Accidental Damage
$
Loss of rent for 6-12 months
$
BUSINESS INTERRUPTION
Gross profits
$
Claims preparation costs
$
Reinstatement of data costs
$
Uninsured working costs
$
Indemnity period
Please make your selection.
3 months
6 months
12 months
18 months
24 months
BURGLARY
Contents
$
Stock in Trade
$
Liquor and/or Tobacco
$
Specified contents
$
MONEY
In Transit
$
During business hours
$
Outside business hours
$
In the personal custody
$
Damage to safe
$
In private residence
$
PLATE GLASS
External Glass
Please make your selection.
Yes
No
Replacement value: $
Internal Glass
Please make your selection.
Yes
No
Replacement value: $
Signs
Please make your selection.
Yes
No
Qty:
Sum Insured: $
LIABILITY
Public liability
Please make your selection.
$10,000,000
$20,000,000
$50,000,000
$100,000,000
Products liability
Please make your selection.
$10,000,000
$20,000,000
$50,000,000
$100,000,000
Goods in physical and legal control
Please make your selection.
$10,000
$20,000
$50,000
$100,000
$150,000
$200,000
$250,000
Do you export?
If you answer Yes to this question, please list the countries.
Please make your selection.
Yes
No
Do you import?
If you answer Yes to this question, please list the countries.
Please make your selection.
Yes
No
What is your annual turnover?
$
State the products you manufacturer, assemble, supply and/or re-pack:
Do you subcontract?
Please make your selection.
Yes
No
What is the total number of proprietors and partners?
What is the total number of staff?
MACHINERY BREAKDOWN
Description of Item
Sum Insured
1.
$
2.
$
3.
$
4.
$
5.
$
6. Deterioration for Stock Sum Insured
$
COMPUTER SYSTEMS / ELECTRONIC EQUIPMENT
Describe the Computer Equipment
(excluding notebook PCs)
Describe the Electronic Equipment
Describe the Notebook PCs
LIMITS AND SCOPE
Geographical limits
Please make your selection.
Australia Wide
World Wide
Scope of cover
Please make your selection.
Fire and Perils
Fire and Perils, Accidental Damage and Theft
GENERAL PROPERTY
Description of Item
Sum Insured
1.
$
2.
$
3.
$
4.
$
5.
$
6.
$
7.
$
TAX INVESTIGATION
Indicate the sum insured for Taxation Investigation costs
Please make your selection.
$10,000
$20,000
$30,000
$40,000
$50,000
EMPOLYEE DISHONESTY
Any one employee or group of employees
Any one period of insurance
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.
Please make your selection.
Yes
No
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.
Please make your selection.
Yes
No
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.
Please make your selection.
Yes
No
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.
Please make your selection.
Yes
No
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.
Please make your selection.
Yes
No
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.
Please make your selection.
Yes
No
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.
