Allied Brands Group Insurance Scheme

Please fill out with as much detail as possible. If in doubt, please contact me at the below details: Ray Windsor Phone Number: (07) 3237 8640 Fax Number: (07) 3237 8699 Email: raywindsor@austcover.com.au

Name of Business *
ABN of Business
Address
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Name * First Last
Email *
Date cover is required * / MM / DD YYYY
Construction of premises
Walls Brick / Concrete Iron Wood Other
If other, please specify:
Roof Concrete Iron AC Sheeting Other
If other, please specify:
Number of floors
Year of Construction
Security at premises
Does the premises have an alarm system? Yes No
If yes, what type? 24 hour monitored Security Cameras Dialler / Radio Local siren only
Are there deadlocks and / or padlocks to all external doors? Yes No
Fire Protection
Does the premises have fire protection? Yes No
If yes, what type? Sprinkler System Hose Reels Fire Blanket Extinguishers
Does the premises have an automatic fire alarm and / or smoke detection? Yes No
If yes, what type? Connected to a Fire Station Connected to an Alarm Monitoring Company Local Siren Only
Are flammable liquids or explosives stored at the premises? Yes No
If yes, please list types and quantaties
Are they kept in an approved flammable goods cabinet or store? Yes No
Other Business Details
Are you the owner of the premises? Yes No
Are any of the buildings or structures subject to heritage listings? Yes No
Is any commercial cooking done at the premises? Yes No
If yes, is it Thermostat Controlled? Yes No
Sum Insured
Buildings $ . Dollars Cents
Contents of Buildings $ . Dollars Cents
Stock in Trade $ . Dollars Cents
Other Property $ . Dollars Cents
Total sum insured and / or limit of insurance $ . Dollars Cents
Gross Profit $ . Dollars Cents
Have you or any director/partner or manager of the business ever been refused insurance, had insurance declined or cancelled or had any special terms or conditons imposed? Yes No
If yes, please confirm
In the last five years has the company or it's Directors or Employees sustained loss or damage (insured or not) which would be covered by the type of insurance which is now being sought? Yes No
If yes, please confirm
We acknowledge that this form is not confirmation of cover and a quotation will be provided * Yes No

Allied Brands Group Insurance Scheme

Allied Brands Group Insurance Scheme

Construction of premises

Security at premises

Fire Protection

Other Business Details

Sum Insured