Registered Office: 33 James Street Burleigh Heads QLD 4220 ABN: 64 088 550 074 Lic No: 246939

Business Insurance Quote Request We will process your quote with major insurance companies in order to find you the best business insurance deal possible. Please complete the form below to enable us to respond to your enquiry as accurately as possible. (allow 1 working day) 1. Business Details 1a. Business Name: 1b. Business Address : 1c. Type of Business: 1d. Number of Staff 1e. Annual Wages Paid: $ 1f. Gross Turnover / Annum $ 1g. Building occupied by -- Choose -- Proposer Tenant Proposer and Tenant 1h. Period occupied by proposer Years 1i. Period in this type of business Years      2. Fire Insurance Details 2a. Age of Building Years 2b. Building has been rewired (if over 40 years old) - Yes No 2c. Height of Building Mtrs 2d. Approx. Area sq. Meters   2e. Condition of Builiding 2f. Value of Contents $ Fire Protection   2g. Single Sprinklers - Yes No 2h. Dual Sprinklers  - Yes No 2i. Water Hydrant - Yes No 2j. Extinguishers - Yes No 2k. Vats - Deep Fryers Thermo Controlled Goods Protection 2l. Goods in open air   - Yes No 2m. Customers work in progress - Yes No 3. Seasonal Stock 3a. Cover Amount $ 3b. Period Required ie. December to March 3c. Extra cost of re-installment $     4. Premesis Details Walls 4a. Block / Brick - Yes No   4b. Timber - Yes No   4c. Iron - Yes No   4d. Fibro - Yes No 4e. Other 4f. Roof - Iron Tiles    4g. Other 4h. Floors - Concrete Timber  4i.  Other     5. Burglary Insurance Details 5a. Alarm -- Choose -- Monitored Local No Alarm 5b. Connection -- Choose -- Landline Securitel Dialler Sensors 5c. Infra Red - Yes No   5d. Glass Breakage Detector - Yes No Deadlocks 5e. All Doors - Yes No   5f. Other 5g. Other -- Choose -- Patrols 24 Security Guard 5h. Made a claim in the last 5 years - Yes No 5i. Details 5j. Have you ever had any insurance canceled or declined Yes No 5k. Have you ever been charged or convicted of any criminal offence or declared bankrupt? Yes No  6 . Insurance Amounts Fire and Accidental Damage 6a. Building $ 6b. Stock $ 6c. Other Contents $ 6d. Removal of Debris $ 6e. Loss of rent $ 6f. Rewriting of records $ Business Interruption 6g. Insurable gross profit $ 6h. Increased cost of working $ 6i. Claims preparation costs $ 6j. Accounts / Loss of debtors $ Burglary 6k. Stock $ 6l. Tobacco / Cigarettes $ 6m. All other contents $ 6n. Theft without forceable entry $   Money 6o. In Transit $ 6p. Business Hours $ 6q. Outside Business hours $ 6r. Seasonal Cover $ ie.Weekends, Public Holidays, Christmas 6s. Locked Safe $ 6t. Residence $ 6u. Safes / Storerooms $ Glass 6w. External - Yes No    6x. Internal - Yes No 6y. Illuminated and Neon Signs $ Liability 6z. Public $ 7a. Products $ General property 7b. General Property $ Electroniac Equipment (Breakdown) 7c. Hardware $ 7d. Data Media $ 7e. Inc. Costs $ Machinery (Breakdown) 7f. Unspecified $ 7g. Specified Items $ 7h. Boiler / Pressure Vessels require certification - Yes No 7i. Food Spoilage $ Goods in Transit 7j. Goods in Transit $ Fidelity Insurance 7k. Number of Staff 7l. Amount of Cover $      8. Contact Details Please enter your contact details below so we can contact you regarding your quotation. 8a. Your Name 8b. Daytime Phone Number 8c. Your Email Address 8d. Your Fax Number 8e. Your Postal Address