Insured Name:
Trading Name:
ABN No.(if applicable):
Postal Address:
Email Address:
Website Address (if applicable):
Telephone No:

Details of the business premises

Type of Business (eg. butcher)
Location of premises (full address)
Website Address (if applicable):

Construction of the business premises

Construction of Walls	Please select Brick Concrete Wood Iron Other
Construction of Floors	Please select Concrete Wood Earth Other
Construction of Roof	Please select Metal Concrete Tile Other
Website Address (if applicable):

How are premises protected?

Sprinkler system	Yes    No
Automatic fire alarm	Yes    No
Fire hoses	Yes    No
Extinguishers	Yes    No
Deadlocks on doors	Yes    No
Bars and/or keylocks on all external windows	Yes    No
Burglar alarm system	Yes    No
If you have an alarm, which type?	Please select Local Dialler Securitel Landline

Is this cover required?    Yes    No

If Yes, please fill in the sums insured required below:

   Building sum insured (includes removal of debris)
   Stock in trade
   All other contents.

Is this cover required?    Yes    No

If Yes, please fill in the sums insured required below:

   Annual business turnover

Is this cover required?    Yes    No

If Yes, please fill in the sums insured required below:

Nil $ 5,000 $10,000 $20,000 $30,000 $40,000 $50,000    Stock in Trade

Is this cover required?    Yes    No

If Yes, please fill in the sums insured required below:

Nil $1,000 $2,000 $3,000 $5,000 10,000 No cover

Is this cover required?    Yes    No

If Yes, the glass will be insured for it's replacement value.

Is this cover required?    Yes    No

If Yes, please select a sum insured:    Please select $ 5,000,000 $10,000,000 $20,000,000

What is your annual business turnover?     $

Do you import/export goods?    Yes    No

If you answered YES, please provide detail of goods imported.

Do you perform work away from your premises?     Yes    No

If YES, what type of work is performed away from your premises?

Sustained any loss, damage, injury or liability in the last five years, whether insured or not?
Yes     No    

Had insurance declined, renewal refused, terminated or special conditions imposed by any insurer?
Yes     No    

Ever been declared bankrupt or gone into liquidation?
Yes     No    

Ever received any threats to life or property
Yes     No    

Had a criminal conviction or conviction pending?
Yes     No    

• they are authorised by each of the other Applicants to make this Declaration,
• the contents of the Declaration are true and complete,
• they are under a continuing obligation to immediately inform the insurer of any change in the particulars or statements contained in this Declaration or in the accompanying documents up until the contract is entered into,
• they authorise the insurer to give or obtain from other insurers or insurance reference bureaus or credit reporting agencies, any information about this insurance or any other insurance held by the Applicant/s.

Name of person making this declaration: