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  • Offices
    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 OFFICE INSURANCE Professional Office 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 Storeys Approx Area sq m Condition of Building Mortgagee Interested Party Fire Protection Single sprinklers Dual sprinklers Hydrants Hoses Extinguishers Fire Alarm Thermal Smoke Detectors 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 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 Increased Cost of Working Claims Preparation

    Original URL path: http://www.brokersnational.com.au/OFFICES.htm (2013-02-03)
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  • Professional Indemnity
    Insured required The excess you wish to pay towards a claim Do you currently have professional indemnity insurance Yes No If yes please provide details below Current Expiry date Current Insurance company Current Indemnity limit Sum Insured Current Excess Premium Payable Please give a clear description of activities to be covered Particulars of Principal s Important Please attach short Resume for each person Name of Principal s Qualifications Professional Associations Details of gross income fees or commissions Received rendered during the last 12 months Gross Income Fees Estimated Income fees for next 12 months Gross Income Fees Are any of your operations located outside of Australia Yes No If the answer to either of the above is Yes please specify which countries and percentage of income deriving from each Have you ever had a liability insurer a Decline a proposal Yes No b Impose special terms Yes No c Decline to renew your insurance Yes No d Cancel your insurance Yes No If the answer to either of the above is Yes please provide details below Have any claims ever been made against you or your firm in business individually or otherwise in respect of this class of insurance Yes No Are any of the Partners Principals Staff aware of any facts or circumstances which are likely to give rise to a claim against the Firm or any of the present or former Partners Principals Yes No Has any principal or staff member been subject to Disciplinary Proceedings for professional misconduct Yes No If the answer to either of the above is Yes please provide details below Under the Insurance Contracts Act you have a Duty of Disclosure Is there any matter not disclosed above or in the attachments that is relevant to the acceptance of this proposal Yes No

    Original URL path: http://www.brokersnational.com.au/PROFESSIONAL_INDEMNITY.htm (2013-02-03)
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  • Personal Travel
    underwriting agencies We aim to find you the best travel 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

    Original URL path: http://www.brokersnational.com.au/personal_travel.htm (2013-02-03)
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  • Directors and Office Bearers
    please provide details I s there any shareholder holding directly or beneficially 10 or more of the ordinary share capital of the Corporation Yes No If Yes please provide the name of the share holder and the percentage held Director Executive Officer Details Are any of the directors currently members of any professional association e g Australian Institute of Company Directors Yes No If Yes please provide details Does the Corporation have an audit or compliance committee Yes No Has any director executive of the Corporation been declared bankrupt Yes No If Yes please provide details Has any director executive of the Corporation been a director of an organisation placed in receivership liquidation or provisional liquidation Yes No If Yes please provide details Has there ever been any acquisition or disposal merger or takeover undertaken by the Corporation or any subsidiaries in the last 24 months Yes No If Yes please provide details Corporation Insurance Details Has the Company or subsidiary ever been refused insurance policy cancelled or declined to renew or any special terms imposed Yes No If Yes please provide details Corporation s Financial Information This Year Last Year Current Assets Cash Debtors Other Total Current Assets Non current Assets Total Assets Current Liabilities Creditors Borrowings Other Total Current Liabilities Non Current Borrowings Other non current Liabilities Sales Profit Are the accounts of the Company consolidated Yes No Are the accounts audited Yes No Have the audited accounts been qualified Yes No If Yes please provide details Have the accounts been certified by the directors as a true and fair view of the company s financial position Yes No Is there any other information of a material nature not disclosed in the financials that could effect the financial position capital structure or operation of the Company Yes No

    Original URL path: http://www.brokersnational.com.au/DIRECTORS_AND_OFFICE%20BEARER.htm (2013-02-03)
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  • Construction
    with most insurers and underwriting agencies We aim to find you the best construction 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 Construction Contract Works General Questions Has the Insured in the last 5 years Been refused any type of insurance or had special terms imposed Yes No Made a claim for any insurance whatsoever Yes No Been bankrupt or had criminal convictions Yes No If Yes to any of the above questions please state full details Construction Particulars Situation Construction Site Description of construction Number of storeys storeys Approximate building area squarage sq metres or sqs Is there alterations additions renovations extensions Is there an existing structure s on the site Details Are existing structure s to be insured for damage arising from construction work Yes No If Yes advice replacement value of existing structure excl contents therein Sum Insured During the construction will there be Demolition Yes No Underpinning Yes No Testing Yes No Blasting Yes No Type of cover Type of cover Single contract Annual cover State annual turnover if applicable State limit in respect of any one contract Sum Insured Sums insured Contract work Temporary work all materials Contract price Sum Insured Materials or items supplied by the principal s Escalation allowance Sum insured for Structures excluding contents located on or adjacent to the site and belonging to or held in care custody or control of the principal s or

    Original URL path: http://www.brokersnational.com.au/CONSTRUCTION.htm (2013-02-03)
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  • Prestige Motor
    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 information Date of birth of main driver M F Percentage of use Occupation of main driver How long has this driver held a drivers licence years Have you had any traffic offences accidents vehicles stolen any other vehicle loss damage and licence suspension or cancellation for the last 5 years Yes No If

    Original URL path: http://www.brokersnational.com.au/PRESTIGE_MOTOR.htm (2013-02-03)
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  • Excavation
    National has accounts with most insurers and underwriting agencies We aim to find you the best excavation 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

    Original URL path: http://www.brokersnational.com.au/EXCAVATION.htm (2013-02-03)
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  • Classic Veteran Motor
    you are over 25 would you like to exclude drivers under 25 from using this vehicle Yes No If you are over 25 would you like to limit drivers to 2 named drivers only Yes No About the vehicle you wish to insure Make Of Vehicle Vehicle Model e g Commodore Type Of Vehicle Series e g VT Year Of Manufacture Body Type Engine capacity litres Turbo Yes No Transmission Manual Automatic Metallic paint List Accessories modifications please give details and value Estimated value of vehicle Including Accessories Is the vehicle a private import Yes No Suburb where the vehicle is parked at night Postcode How will it be parked Private garage Pay parking On street Off street Please select from list Suburb where the vehicle is parked during the day Postcode How will it be parked Private garage Pay parking On street Off street Please select from list Is Laid Up cover required during Restoration Yes No 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 Do you have any car club memberships give details 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 information Date of birth of main driver M F Percentage of use Occupation of main driver How long has this driver held a drivers licence years Have you had any traffic offences accidents vehicles stolen

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