Business Insurance Quotation Form
Please complete the details below and we will obtain a quotation on your behalf:
Required Fields (*)
*
Contact Name:
*
Ph:
Fax:
*
Email:
*
Company:
*
Renewal Date:
format: mm/dd/yy
*
Business
Description:
Years in
Business:
*
Location:
Years at Situation:
Construction:
*
Walls:
- Please Select -
Brick
Concrete
Metal
Other
*
Floors:
- Please Select -
Concrete
Timber
*
Roof:
- Please Select -
Concrete
Metal
Tile
*
No. of Storeys
*
Protection:
Sprinklers
Fire Hydrant
Hose Reels
Extinguishers
Back to Base Securitel Alarm
Back to Base Dialer Alarm
Local Alarm
Deadlocks
Bars/Grills
Other
Information:
*
No. of Employees:
*
Estimated Turnover:
$
*
Estimated Payroll:
$
*
Claims/Losses Last 3 Years:
(Date/Description/Amount/Insurer)
*
Current
Insurer:
Current
Broker:
Current
Premium:
$
POLICY DETAILS
Fire & Perils
Liability
Building
$
General
$
Stock in Trade
$
Products
$
Other Contents
$
Property in Physical
& Legal Control
$
Removal Of Debris
$
Driving Risk
$
Other
$
Business Interruption
Glass Breakage
Gross Profit
$
External
Yes
No
Weekly Benefits
$
p/w
Internal
Yes
No
Increased Costs
of Working
$
Signs
$
Claims Preparation Fees
$
Other
$
Accidental Damage
$
Other Information
Burglary
Stock in Trade
$
Other Contents
$
Damage to Premises
$
Money
In Transit
$
On Premises during
$
Business Hours
$
On Premises outside
Business Hours
$
In Safe
$
In Personal Custody
$