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  • Standard Motor
    type please select from list Full Comprehensive Third Party Fire and Theft Third Party Only Laid Up Policy options Would you like to pay extra to include one windscreen claim per year which doesn t affect your No Claim Bonus Would you like to include No Claim Bonus Rating 1 Protection retain your NCB even if you have an accident which is your fault Would you like to exclude drivers under 25 from using this vehicle Would you like to restrict drivers to 2 named people only About the vehicle you wish to insure Make Of Vehicle Vehicle Model e g Falcon Camry Commodore etc Type Of Vehicle e g GL GLX etc Series e g FJ VC VT VXi etc Year Vehicle Manufactured Body type Sedan Wagon etc Engine capacity in litres Turbo Transmission Manual Automatic 4 Wheel Drive Accessories modifications please give details and value Estimated value of vehicle Suburb vehicle will be parked at night Postcode Where will it be parked Private garage Pay parking On street Off street Please select from list Suburb vehicle will be parked during the day Postcode Where will it be parked Private garage Pay parking On street Off street Please select from list How often is the car used Approximate distance travelled per year kms What purpose is the vehicle mainly used for Private Business Hire Goods Carrying Please select from list What is the ownership status of the vehicle Paid up and fully owned Leased Hire purchase Bank loan Please select from list Security information about the vehicle Does the vehicle have any anti theft equipment Yes No If yes please specify Audible alarm only Alarm engine immobiliser 2 point Lock tight deadlocking Steering lock Mobile tracking Self arming passive immobiliser 3 point Ignition kill switch Other please specify Driver

    Original URL path: http://www.brokersnational.com.au/STANDARD_MOTOR.htm (2013-02-03)
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  • Been Sent To Brokers National Please continue to review our site The following information has been delivered Warning mail function mail SMTP server response 503 Bad sequence of commands You must specify the recipients of a message before you can

    Original URL path: http://www.brokersnational.com.au/mail.php (2013-02-03)
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  • Commercial
    Details Your Current Insurer Due Date Situation of Risk Postcode Business Trading Name Company Or Partnership Names Occupation Trade Business Number of Staff Full Time PartTime Approx Annual Wages per annum Estimate Sales Turnover Rentals per annum Building Occupied By Select Please Proposer Tenant Proposer Tenants Vacant Building Years In This Business years Fire Insurance Details Approx Age of Building yrs No Of Stories Approx Area sq m Condition of Building Mortgagee Interested Party Fire Protection Single sprinklers Dual sprinklers Hydrants Hoses Extinguishers Fire Alarm Thermal Smoke Detectors Cooking Free Standing Frying Vat Thermostatically Controlled Bench Top Frying Vat Griller Pizza Oven Rotisserie Woks Construction Details Walls Bricks Concrete Iron Timber Fibro Mixed Construction Is Roof Iron Tiles Other Floors Concrete Timber Mixed Other Security Details Details about anti theft protection you currently have Alarm Monitored Local Sounding No Alarm Connection Landline Securitel Dialler No Connection Sensors Infra Red Window Detector Tapes Deadlocks All Doors Other Other Security Patrols 24 hour Security Guard Roller Shutter Front Window Bars Front Windows Bars Rear Windows Safe On Premises Please detail briefly any insurance claims in the last five years IMPORTANT Have you ever Had any insurance cancelled or declined Yes No Been charged or convicted of any criminal offence Yes No Been bankrupt Yes No Liability Details Sub Contractors Do You Employ Sub Contractors Do They Have Insurance Give Details Welding In Own Factory Inside Client Premises Outside On Site Activities Manufacturing Distribution Installation Repairs Entertainment Band Disco Solo Duo Dance Floor Other Importing Yes No Countries Imports Exporting Yes No Countries Exports List Sum Insured Required Please enter the value to be insured against each item Fire and Accidental Damage Building Stock Other Contents Removal of Debris Loss of Rent Other Specified Property Accidental Damage Business Interruption Gross Profit or Rent

    Original URL path: http://www.brokersnational.com.au/COMMERCIAL.htm (2013-02-03)
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  • Home and Contents
    best home contents insurance deal possible Please fill in the following form answering all questions then either 1 Click on Email to Brokers National at the bottom of this form OR 2 Highlight this form to Print It and then Fax It to our office on 03 9791 6633 Use the Mouse or the Tab key to move to the next field We will respond with quotes as soon as they have been received from our insurers HOME OR CONTENTS About the property you wish to insure Postcode of property Approximate Age of house years Date of Birth of the oldest person at home Is that person retired Yes No Is that person a pensioner Yes No Construction pf home Brick Concrete Wood Hardiplank Fibro Cement Please select from list Current occupancy status Owner occupied Tenanted i e contents insurance only Holiday home Landlord Currently Vacant Please select form list Is the house on more than 1 acre of land Yes No Is the house in Neighbourhood Watch area Yes No Is the house connected to town water Yes No the value of insurance you are seeking Building sum insured Contents sum insured Extra protection for accidental loss or damage this is an additional cost Unspecified Valuables Specified Valuables Art Music Jewellery Photographic equipment Bikes Computers Laptops Phones Excess you would prefer to pay on this policy Excess is the amount you pay out of each claim you make 100 250 500 1000 Please select from list Security information about the house Doors Are there deadlocks on all external doors Yes No Do all sliding doors have patio bolts Yes No No sliding doors Windows Are there keyed locks on all windows Yes No Do any windows have bars Yes No Details Other security information What kind of alarm system

    Original URL path: http://www.brokersnational.com.au/HOME_AND_CONTENTS.htm (2013-02-03)
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  • Industrial
    received from our insurers Business Details Only Complete This Form If Sum Insured Is Over 2m For All Situations If Sum Insured Is Under 3m Then Click On Commercial Your Current Insurer Due Date Situation of Risk Postcode Business Trading Name Company Or Partnership Names Occupation Trade Business Number of Staff Full Time PartTime Approx Annual Wages per annum Estimate Sales Turnover Rentals per annum Building Occupied By Select Please Proposer Tenant Proposer Tenants Vacant Building Years In This Business years Property Insurance Details Approx Age of Building yrs No Of Stories Approx Area sq m Condition of Building Morgagee Interested Party Fire Protection Single sprinklers Dual sprinklers Hydrants Hoses Extinguishers Fire Alarm Thermal Smoke Detectors Cooking Free Standing Frying Vat Thermostatically Controlled Bench Top Frying Vat Griller Pizza Oven Rotisserie Woks Construction Details Walls Bricks Concrete Iron Timber Fibro Mixed Construction Is Roof Iron Tiles Other Floors Concrete Timber Mixed Other Security Details Details about anti theft protection you currently have Alarm Monitored Local Sounding No Alarm Connection Landline Securitel Dialler No Connection Sensors Infra Red Window Detector Tapes Deadlocks All Doors Other Other Security Patrols 24 hour Security Guard Roller Shutter Front Window Bars Front Windows Bars Rear Windows Safe On Premises Please detail briefly any insurance claims in the last five years IMPORTANT Have you ever Had any insurance cancelled or declined Yes No Been charged or convicted of any criminal offence Yes No Been bankrupt Yes No Liability Details Sub Contractors Do You Employ Sub Contractors Do They Have Insurance Give Details Welding In Own Factory Inside Client Premises Outside On Site Activities Manufacturing Distribution Installation Repairs Entertainment Band Disco Solo Duo Dance Floor Other Importing Yes No Countries Imports Exporting Yes No Countries Exports List Sum Insured Required Please enter the value to be insured

    Original URL path: http://www.brokersnational.com.au/INDUSTRIAL.htm (2013-02-03)
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  • Landlords
    It and then Fax It to our office on 03 9791 6633 Use the Mouse or the Tab key to move to the next field We will respond with quotes as soon as they have been received from our insurers LANDLORDS About the property you wish to insure What is the address of the property you wish to insure Postcode Do you owe money on this property Yes No If Yes what are the lender s name and address What type of building is it Private house Unit or flat Other please specify Is the building currently occupied Yes No If No when will the building be permanently occupied What are the walls of your building made of Brick Wood Fibro Other please specify Age of building Years What is the size of the building Squares OR Square Metres About the value of insurance you are seeking Landlords Building details below Do you want cover for a Replacement value Yes If Yes what is the replacement cost of your building Fixtures Fittings Contents details below Total replacement cost of listed items Loss of rent What is the amount of loss of rent you want to insure Rent Default and Tenant Theft Do you want cover for Rent Default and Tenant Theft Yes No Property Owners Liability Please select the the amount of liability cover required 5 000 000 OR 10 000 000 Is there a swimming pool on the property Yes No Questionnaire 1 Is the building a holiday house holiday unit or holiday weekender Yes No If Yes how often is it visited If Yes how far away is the nearest occupied home Metres 2 Do any parts s of the buildings need repairing or replacing e g gutters stumping electrical pluming roof Yes No If Yes describe repair

    Original URL path: http://www.brokersnational.com.au/LANDLORDS.htm (2013-02-03)
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  • Retail Shops
    as they have been received from our insurers Retail Shop Details Your Current Insurer Due Date Situation of Risk Postcode Business Trading Name Company Or Partnership Names Occupation Trade Business Number of Staff Full Time Part Time Approx Annual Wages per annum Estimate Sales Turnover Rentals per annum Building Occupied By Select Please Proposer Tenant Proposer Tenants Vacant Building Years In This Business years Fire Insurance Details Approx Age of Building yrs No Of Stories Approx Area sq m Condition of Building Mortgagee Interested Party Fire Protection Single sprinklers Dual sprinklers Hydrants Hoses Extinguishers Fire Alarm Thermal Smoke Detectors Cooking Free Standing Frying Vat Thermostatically Controlled Bench Top Frying Vat Griller Pizza Oven Rotisserie Woks Baking Ovens Construction Details Walls Bricks Concrete Iron Timber Fibro Mixed Construction Is Roof Iron Tiles Other Floors Concrete Timber Mixed Other Security Details Details about anti theft protection you currently have Alarm Monitored Local Sounding No Alarm Connection Landline S ecuritel Dialler No Connection Sensors Infra Red Window Detector Tapes Deadlocks All Doors Other Other Security Patrols 24 hour Security Guard Roller Shutter Front Window Bars Front Windows Bars Rear Windows Safe On Premises Please detail briefly any insurance claims in the last five years IMPORTANT Have you ever Had any insurance cancelled or declined Yes No Been charged or convicted of any criminal offence Yes No Been bankrupt or placed in administration Yes No Liability Details Sub Contractors Do You Employ Sub Contractors Do They Have Insurance Give Details Entertainment Band Disco Solo Duo Dance Floor Other Importing Yes No Countries Imports Exporting Yes No Countries Exports List Sum Insured Required Please enter the value to be insured against each item Fire and Accidental Damage Building Stock Other Contents Removal of Debris Loss of Rent Other Specified Property Accidental Damage Business Interruption Gross

    Original URL path: http://www.brokersnational.com.au/RETAIL_SHOPS.htm (2013-02-03)
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  • Residential Strata
    Use the Mouse or the Tab key to move to the next field We will respond with quotes as soon as they have been received from our insurers Residential Strata About the property you wish to insure What is the construction of the walls What is the construction of the roof What is the number of storeys other than ground floor Age of building Years How many lifts and or escalator and or hoists are there How many swimming pools and or spas are there Are there any other recreational facilities No Yes If Yes what are they Are any parts of the buildings used for any purpose other than residential No Yes If Yes describe what that part is used for Are the buildings managed by an authorised strata management company No Yes If Yes what is the name of the person or company Buildings and Common Property What is the replacement cost of your buildings Liability S elect the the amount of Liability cover required 10 000 000 15 000 000 20 000 000 25 000 000 Fidelity Guarantee Theft Of Funds What is the amount of Fidelity cover required Office Bearers Liability What is the amount of Office Bearers Liability cover required Personal Accident Voluntary Workers Cover is for injury while engaged in administrative or light maintenance duties arranged by the Body Corporate Do you want cover for Personal Accident No Yes If Yes how many units of cover do you require units Questionnaire Have any of the applicants suffered any losses or had any claims made against them within the last 5 years whether claimed or not No Yes If Yes complete the following details Type of loss or claim Date Amount Name of insurer if applicable Have any of the applicants or any person who

    Original URL path: http://www.brokersnational.com.au/RESIDENTIAL_STRATA.htm (2013-02-03)
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