Insurance Quotation
 
 

Please complete all the field that are appropriate to your business or property. It is advised you read our privacy policy before filling in the form.

Fields marked * are required
* Your name
 
Business name
 
* Your email
 
Your phone
 
Your fax
 
Your mobile
 
   
Address of premises to be insured
 
Type of business
 
Age of building
  

Construction
  
walls
brick veneer
 timber
 mixed
other

roof
concrete
iron
tile
asbestos
thatched
other

floors
concrete
timber
mixed
other
     

Security
  


watchman
patrols
window locks
deadlocks
bars
 alarm monitored
smoke detectors
smoke detectors are hardwired
 sprinklered
 extinguishers
 fire hose reels
     

History
Has the Director, Partner or the Business had:

    
Insurance declined, refused or cancelled?
   yes no
Any convictions or been declared bankrupt?
   yes no
Entered or hold harmless or similar agreements?
   yes no
Have any claims or losses over the last five years?
   yes no
Claims details - summary last 5 years
  
     
Insurance
    
Fire
  

$ Sum Insured

Building includes Landlord's fixtures
 $
Stock & work in progress
 $
Contents, machinery & plant
 $
Accidental Damage
$
Other
   $
specify
 
Consequential Loss
 

$ Sum Insured

Turnover
 $
Cost of Sales
   $
Annual Gross Profit
   $
Claims preparation costs
 $
Additional increased costs of working
   $
Insured payroll Indemnity period (plus months)
 $
Indemnity period
 
specify
 
Burglary
  

$ Sum Insured

Stock, work in progress
 $
All other contents
 $
Other
 $
specify
Money
  

$ Sum Insured

On money in transit
 $
On money contained in work premises
 $
During business hours
 $
Outside business hours
 $
Whilst contained in locked safe
$
On money in personal custody
 $
On damage to safes
 $
Glass Coverage
 
Is cover required?
 yes no
Illuminated signs
$
Public or Property Owners Liability
  

$ Sum Insured

Public Liability
$
Products Liability
 $
Goods in care, custody, control
 $
Machinery Breakdown
 

$ Sum Insured

Limit one breakdown
 $
Please list equipment
Electronic Equipment
 

$ Sum Insured

Limit one breakdown
 $
Please list equipment
Employee Fraud
 

$ Sum Insured

Limit one loss
 $
Information
Number of people in business
 Full Time Part Time
Annual turnover
 $
     
Enter the code as it is shown:

 

We will contact to discuss your insurance requirements and obtain further information from you once form has been submitted to us.
 
 

 
Home   |    Search This Site   |   Privacy Policy   |  Financial Services Guide   |   Contact Us

Citycover (Aust) Pty Ltd - GPO Box 851, Brisbane QLD 4001 Tel (07) 3270 1500 - Fax (07) 32701501 - ADSL 241087

© Site created and maintained by DigiTouch® Marketing