City Rural

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Business Pack

The insurance on your business is able to be tailored to your specific needs and requirements, you may take out cover on a variety of sections listed and ask for sections if they are not listed. We will review the quotes and select the policy that best suits your requirements.

In order for City Rural Insurance Brokers to provide you with an Obligation Free Quote, please complete the following.

Fields designated in RED require completion

GENERAL INFORMATION
Insured's name	Contact Name (if different)
Trading name	Subsiduaries
Postal address	Suburb/Town
State	Postcode
Email Address	Phone
Fax	Mobile Phone
Preferred method of contact Email Phone Fax	Occupation/Profession
Experience in business (Years)
Current Insurer	Expiry date
Has any insurer in respect of any insurance policy held by you ever:

(a) Refused to renew / cancelled or terminated a policy

Yes No

If yes, please supply details.

(b) Refused a claim or required an increased premium under the policy?

Yes No

If yes, please supply details.

(c) Imposed special conditions under the policy?

Yes No

If yes, please supply details.

(d) Have you been convicted on any criminal offence or been declared bankrupt?

Yes No

If yes, please supply details.

(e) Have you had any claims in the past 5 Years inc Workers Compensation?

Yes No

If yes, please supply details.

PROPERTY DETAILS
Street address	Suburb/Town
State	Postcode
Construction
Walls Roof Floors Age
Details of Security
Deadlocks Yes No	Bars Yes No
Bollards Yes No	Fencing Yes No
Shutters Yes No	Window Film Yes No
Alarm Yes No if Yes is it? Local Monitored Dialer Securitel
Fire Protection
Smoke Detectors Yes No	Extinguishers Yes No
Fire Hose Reels Yes No	Smoke Detectors attached to Alarm System Yes No

FIRE & SPECIFIED PERILS
Value of Building(s)	Value of stock including work in progress
Value of Customers Goods	Value of Contents
BUSINESS INTERRUPTION
Annual Gross Profit	Claims Preparation Costs
Additional Increased Cost of Working	Gross Loss of Rent
Other	Indemnity / Benefit Period (Months)
BURGLARY /THEFT OF PROPERTY
Value of stock in trade	Value of customers Goods
Value of tobacco, cigars and/or cigarettes	Liquor value
Other contents
MONEY
Money in transit	Money on premises - business hours
Money on premises - O/S business hours	Money on premises - in locked safe
Money in private residence & Personal Custody
GLASS BREAKAGE
External Glass /Internal Glass (replacement value): Yes No
External Only Internal Only Internal/External
Advertising Signs	Damage to Stock
LIABILITY SECTION 1 - Public & Products Liability
Limit of Indemnity: $5,000,000 $10,000,000 $20,000,000

Any Welding or Hot Work Yes No

If Yes the provide details of work done and % of income

OTHER DETAILS
(a) Does the business manufacture/modify/alter any product?	Yes No

If Yes, the provide details of work done and % of income

(b) Are any products IMPORTED by you / your business?

Yes No

If yes state
Type of Goods
Country of origin Approx value
Type of Goods
Country of origin Approx value
Type of Goods
Country of origin Approx value

(b) Are any products EXPORTED by you / your business?

Yes No

If yes state
Type of Goods
Destination Approx value
Type of Goods
Destination Approx value
Type of Goods
Destination Approx value

Annual estimated turnover (sales)	Employees wages
Proprietors/Directors wages	Number of people in business at any one time

Does business engage sub contractors?
Yes No

Number of sub contractors involved	Estimated total value of sub contractors
Type of work sub contracted to others

Are unregistered vehicles used in business?
Yes No

If yes, state details

Is cover required for Goods in Physical & Legal Control?
Yes No

If yes, state type of goods and amount of cover required

Previous losses/claims for Public Liability
How many years have you had experience in this type of business years
Have you recently completed any Business Management Courses or a New Enterprise Incentive Scheme (NEIS)? Yes No

MACHINERY BREAKDOWN (up to 4hp)
Blanket
Description & No of Items	Maximum any one loss	H/P value or kW value
Specified Items
Description		H/P value or kW value
Spoilage of Stock
Description of Stock		Value
ELECTRONIC BREAKDOWN
Description		Value
Electronic Equipment
Accidental Damage including Fire & Perils, Theft & Breakdown: Yes No
Specified Items
Description		Value
Portable Items (Outside Premises)
Cost of Restoring Data	Increased cost of working
Additional policies available:
Travel, Contract Works, Director & Officers, Tax Audit, Fraud, Professional Indemnity Please send me information on the selected classes listed above.

I have read the Duty of Disclosure (view)
Duty of Disclosure In order to make an informed assessment of the risk and calculate the appropriate premium, your insurer needs information about the risk you are asking it to insure. For this reason, before you enter into a contract of insurance, you have a duty under the Insurance Contracts Act 1984 to disclose to your insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer’s decision whether to accept the risk and, if so, on what terms. The duty also applies when you renew, extend, vary or reinstate a contract of insurance. You do not have to disclose anything that: Reduces the risk to be undertaken by the insurer; Is common knowledge; Your insurer knows, or in the ordinary course of its business, ought to know; or If the insurer has waived your obligation to disclose. If you do not comply with your duty of disclosure, your insurer may be entitled to reduce its liability in respect of a claim or may cancel your contract of insurance. If the non-disclosure was fraudulent, the insurer may be able to avoid (or cancel) the contract of insurance from its beginning. This would have the effect that you were never insured. One important matter to be disclosed is the history of losses suffered by the person seeking insurance or any closely associated person or entity. As you are responsible for checking that you have made complete disclosure, we suggest that you keep an up to date record of all such losses and claims.

Signature Title	Dated

Member of National Insurance Brokers Association and Steadfast Group Limited

Australian Financial Services Licence No 237491 – General Insurance Broker

Affiliations