Mr. Mrs. Ms         First Name       Surname   

Risk Address
    Vic NSW Qld S.A. W.A. Tas    Postcode   

Fire & Perils

Brick walls Concrete walls Timber walls Other    Construction    Not sprinklered Sprinklered    Fire Protection

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

Business Interruption

   Gross Profits      Not required 12 months 9 months 6 months    Indemnity period
Nil $10,000 $20,000 $30,000 $40,000 $50,000    Claims Preparation Costs
Nil $20,000 $40,000 $60,000 $80,000 100,000    Additional costs involved in keeping the business operating
Nil $10,000 $20,000 $30,000 $40,000 $50,000    Book Debts   

Accidental Damage

Nil $10,000 $20,000 $30,000 $40,000 $50,000    ($10,000 cover is automatic. Extra cover is available)

Burglary

Nil $10,000 $20,000 $30,000 $40,000 $50,000    Contents (also includes stock & all other equipment)

Do you have an alarm system?
   None
   Local
   Monitored   

Money

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

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

Glass

Replacement Cost No cover required

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

Public Liability

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

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

Have you or anyone to be insured under this policy:

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    

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

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