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

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