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Business/Rooms Insurance Quote
Name of Entity
ABN
Trading name
Practice address
Street Address
City
State
Postcode
When did/will the practice commence
Estimated gross revenue next 12 months
Number of directors
Number of employees
Number of contractors/room rental
Are you:
The building owner
The tenant
Renting sessional space
Name of financier
Do you currently have business package cover?
Yes
No
Insurer name
Due date
Total annual premium
Have you had any business package claims in the past?
Yes
No
Number of claims
Total paid by insurer
Describe the claim/s
Policy Section
Property – fire and perils cover
Building
Contents, fitout, equipment
Stock
e.g. vaccines
Property – theft cover
Contents, fitout, equipment
Glass
Glass breakage
Business Interruption
Gross annual revenue
Public & Products liability
Gross annual revenue
$10m
$20m
Do you manufacture or import any products for sale?
Yes
No
Money
Do you require cover for theft of money?
Yes
No
Portable equipment away from premises
If you require cover for any portable equipment outside of the premises, please provide the following:
Value
Describe Items
Equipment Breakdown
Do you require equipment breakdown cover for air-conditioning?
Value
Describe items
Do you require equipment breakdown cover for office computer equipment?
Value
Describe items
Do you require equipment breakdown cover for medical equipment?
Value
Describe items
Do you require cover for
Rewriting of data
Spoilage of stock following breakdown
Lost revenue following breakdown
Tax Probe
Do you require cover for accounting costs for a tax investigation or audit?
Not required
$10,000
$20,000
$50,000
Details of premises
General details
Year built
Is it heritage listed?
Yes
No
Strata or owned building?
Have/will you be doing fitout?
If there is a formal lease document, please attach it here
Accepted file types: pdf, jpg, jpeg.
Describe your practice premises
Construction
Roof
Iron/Steel/Concrete
Tile
Other
Walls
Brick/Concrete
Timber frame
Other
Floor
Concrete
Timber
Is there any expanded polystyrene (EPS) in the construction of the building?
Yes
No
Security
