CRM ELECTRONIC EQUIPMENT PROPOSAL FORM

Transcription

1 CRM ELECTRONIC EQUIPMENT PROPOSAL FORM This proposal must be fully completed in ink by a Partner, Director or Principal of the Firm. If there is insufficient space to answer any questions use additional sheets of the Firm s headed paper and attach to the form. (Full names of all persons and companies to be Insured) SECTION A GENERAL Name Trading Name ABN What proportion of this insurance premium are you claiming as an Input Tax Credit? % Insured Postal Address Phone Business Fax Phone Private Mobile Describe the main activities of the Insured s Business Number of Years the Business has been established Number of employees (including proprietors, directors and partners)

2 Estimated annual turnover Wage Roll Name of Other Interested Parties Address of Other Interested Parties Has any insurance company refused to meet a claim lodged by the Insured or by any party to be covered? Has any insurance company succeeded in denying a claim lodged by the Insured or by any party to be covered on the grounds of non-disclosure, misrepresentation and/or fraud in respect of the cover required? Does the insured have or intend to have any additional insurance with any other Insurer in connection with this cover in respect of the same property or risk as are now proposed.

3 Is there any additional information or detail of which the Insured is aware which may assist us to better assess the nature of the risk Has any insurance company in connection with this cover: (a) declined to accept a proposal from you (b) cancelled a policy, contrary to your wishes (c) declined to renew a policy, contrary to your wishes List all claims and uninsured losses, damage or liabilities that have involved the insured during the last five years. Date of Loss Description Insurer Amount

4 SECTION B PROPERTY Is cover required for property? If yes, answer all questions below The following information is required for each location to be insured (attach additional information if more than one location) Address of premises to be Insured Type of activity carried on at location Approximate age of premises years Construction: Walls Roof Floors Sprinklered Burglar Alarm

5 SECTION C ELECTRONIC EQUIPMENT Please answer all of the questions below. Part A Material Loss or Damage Specified Items Optional Extensions of cover 1. The cost of Restoring Data $ 2. Increased Cost of Working $ Part A Material Loss or Damage Excess $ Part B Breakdown Specify items to be covered below Description Value Optional Extensions of Cover 1. The cost of Restoring Data $ 2. Increased Cost of Working $ Part B Breakdown Increased Cost of Wording Excess days

6 Name of Proposer Signed by On behalf of all Partners/Directors/Principals Date Please complete and return to: Fax: Post: CRM Brokers, PO Box 6542, Baulkham Hills Business Centre 2153 Phone: