Dr. Mr. Mrs. Ms    First Name     Surname  

Business Name

Risk Situation
   Postcode

Email Address

Tel.No.       Fax No.   

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Fire & Perils    (Including Accidental Damage cover)

   Building sum insured (includes removal of debris)
   Contents sum insured (include stock & all other equipment)

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Business Interruption

    Gross fee income per year
Not required $10,000 $20,000 $30,000    Claims Preparation Costs
Not required $25,000 $50,000 $75,000    Additional costs involved in keeping the business operating
Not required $10,000 $20,000 $30,000 $40,000    Book Debts
Not required $10,000 $20,000 $30,000    Costs of rewriting your records

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Burglary

Not required $10,000 $20,000 $30,000 $40,000 $50,000    Contents (also includes stock & all other equipment)

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Money

Not required $3,000 $4,000 $5,000 $10,000

Money is covered whilst on your premises during business hours and after business hours (limit $1,000 after hours unless in a safe), in transit to your bank and your home and whilst kept at your home overnight until next banking day.

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Glass

Not required Replacement

Automatically covers external/internal glass plus $1,000 for signwriting, shuttering etc.

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Public Liability

Not required $ 5,000,000 $10,000,000

Includes cover for "Goods in Your Legal Care, Custody or Control" (Limit $50,000)

Have you or anyone to be insured under this policy:

Sustained any loss, damage, injury or liability in the, last 5 years, whether insured or not?
Yes    No

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

Had a criminal conviction or chargee (other than motoring offences)?
Yes    No

If you answered "Yes" to any of the above, please give details.