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Market Stall Liability Insurance
Public & Products Liability insurance specifically designed to cover the needs of Market Stallholders. This policy will provide protection to you, where you have a liability at law for property damage &/or bodily injury to another person.

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

Fields designated in RED are required to be completed
Please complete this form and either:
Fax: (08) 8100 0899

Post: City Rural Insurance Brokers Pty Ltd
PO Box 7138, Hutt Street, Adelaide

Hand deliver to : City Rural Insurance Brokers Pty Ltd
229 Hutt Street, Adelaide SA 5000

Phone Enquiries: (08) 8100 0800
Interstate Enquiries: 1300 887 429
PERSONAL INFORMATION
Name of Person seeking insurance
 Company Name
Address
 Suburb/Town
State
 Postcode
Email Address
 Phone
Fax
 Mobile Phone
Preferred method of contact
Email   Phone   Fax 		Occupation
Period of Insurance

From: Inception commences from date payment & application received & approved by City Rural Ins Brokers
To: 12 Months after the "inception date" to the last day of that particular month at 4.00pm

Are you or have you previously been insured against the risks to be insured? Yes No
If Yes, please provide full details
Have you had any claims made against you (whether insured or not)? Yes No
If Yes, please provide full details
Have you had any incident or accident occur which would have been covered by the proposed insurance policy? Yes No
If Yes, please provide full details
Have you had any insurance declined or cancelled, proposal rejected, renewal refused, claim rejected, special conditions or special excess imposed by an insurer? Yes No
If Yes, please provide full details
Have you ever been convicted of a criminal offence? Yes No
If Yes, please provide full details
Location of market(s) where stall/booth is to be situated:
Business/Market Location
 Suburb/Town
State
 Postcode
Is your stall/booth to be located:

Inside enclosed premises Outside Both
Size of area to be occupied:

Less than 15 sqm Less than 25 sqm Less than 30 sqm
Estimated total number of market days to be attended per annum
 Estimated Gross Sales / Income (before any expenses for stall, stock etc deducted per annum)
$
Please provide full description of goods sold or displayed:
(a) 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