Commercial Insurance Application

Commercial Insurance Application IMPORTANT Commercial NOTICE RELATING Insurance TO THIS APPLICATION Application Please read this section before you complete the Application. IMPORTANT NOTICE RELATING Commercial IMPORTANT NOTICE RELATING TO THIS APPLICATION Insurance TO THIS APPLICATION Please read this section before you complete the Application. Please read this section before you complete the Application. IMPORTANT HOW TO CONTACT NOTICE ACERTA: RELATING TO THIS APPLICATION Please enquiries@acerta.com.au read this section before you complete the Application. HOW TO CONTACT ACERTA: Ph: HOW 1300 TO 223 CONTACT 782 ACERTA: enquiries@acerta.com.au enquiries@acerta.com.au HOW DUTY Ph: 1300 TO OF 223 CONTACT DISCLOSURE 782 Ph: 1300 223 782 ACERTA: Under the Insurance Contracts Act 1984, You have a duty of disclosure. This means before You enter into a contract enquiries@acerta.com.au of DUTY general OF insurance DISCLOSURE Ph: DUTY 1300 OF 223 DISCLOSURE with an insurer, You have a duty to disclose to the insurer every matter that You know, or could reasonably Under the Insurance be expected 782 Contracts to know, Act is 1984, relevant You to have the insurer s a duty of decision disclosure. whether This means to accept before the risk You of enter insurance into a contract Under the Insurance Contracts Act 1984, You have duty of disclosure. This means before You enter into contract and, if so, of general on what insurance terms. with an insurer, You have a duty to disclose to the insurer every matter that You know, or could DUTY of general OF insurance DISCLOSURE with an insurer, You have duty to disclose to the insurer every matter that You know, or could reasonably be expected to know, is relevant to the insurer s decision whether to accept the risk of insurance and, if YOUR Under reasonably the DUTY Insurance be expected OF DISCLOSURE Contracts to know, Act is 1984, relevant You to have the insurer s a duty of decision disclosure. whether This means to accept before the risk You of enter insurance into a contract and, if You so, on have what the terms. same duty to disclose those matters to the insurer before You renew, extend, vary or reinstate a Before of so, general on what contract You of insurance general enter terms. into insurance. with an insurance insurer, contract, You have You a duty have to a disclose duty to tell to the Us anything insurer every that You matter know, that or You could know, reasonably or could be reasonably You expected have the be to same expected know, duty may to affect know, disclose Our relevant those decision matters to to the to insurer s the You insurer decision and before what whether You terms. renew, to accept You extend, have the this vary risk duty of or insurance reinstate until We a agree and, if to insure so, You have You. what the You terms. same have duty the to same disclose duty those before matters You renew, to the extend, insurer vary before reinstate You renew, an insurance extend, vary contract. or reinstate Your contract duty of does general not insurance. contract of general insurance. require disclosure of any matter: You that do have not diminishes the need same to the duty tell Us risk to anything to be undertaken disclose that: by the insurer; Your those matters to the insurer before You renew, extend, vary or reinstate that duty is does of common not require knowledge; disclosure of any matter: a contract Your reduces duty of does the general not risk insurance. require We insure disclosure You for; of or any matter: is that common Your diminishes insurer knowledge; the knows risk or to or, be in undertaken the ordinary by course the insurer; that diminishes the risk to be undertaken by the insurer; of its business, ought to know; We as that to Your know is which of common duty or compliance does should knowledge; that is of common not require knowledge; with as an Your insurer; duty is disclosure of or waived by the insurer. any matter: We that waive Your insurer that Your duty knows diminishes the to tell or, risk Us in to about. the ordinary course of its business, ought to know; that Your insurer knows or, be in undertaken the ordinary by course the insurer; of its business, ought to know; as to which compliance with Your duty is waived by the insurer. that as to is which of common compliance knowledge; with Your duty is waived by the insurer. IF Under YOU the DO that Insurance NOT TELL Your insurer Contracts US SOMETHING knows or, Act in 1984, the You ordinary have a course duty of of its disclosure. business, This ought means to before You enter into a contract If know; of You general do not as to insurance tell Us anything which with compliance insurer, You are with You required Your have to, duty is a duty We waived to may disclose cancel by the to Your the contract insurer every or reduce matter the that amount You know, We will or pay could You insurer. reasonably Under if You the make Insurance be expected a claim, Contracts to or know, both. Act If is Your 1984, relevant failure You to have to the tell insurer s a Us duty is fraudulent, of decision disclosure. whether We This may means to refuse accept before to the pay risk You a claim of enter insurance and into treat a contract and, the Under the Insurance Contracts Act 1984, You have duty of disclosure. This means before You enter into contract if contract so, of general what as insurance if terms. it never with existed. an insurer, You have a duty to disclose to the insurer every matter that You know, or could of general insurance with an insurer, You have duty to disclose to the insurer every matter that You know, or could reasonably be expected to know, is relevant to the insurer s decision whether to accept the risk of insurance and, if Under reasonably the Insurance be expected Contracts to know, Act is 1984, relevant You to have the insurer s a duty of decision disclosure. whether This means to accept before the risk You of enter insurance into a contract and, if PRIVACY so, on what terms. of so, general on what insurance terms. with an insurer, You have a duty to disclose to the insurer every matter that You know, or could We respect reasonably Your be rights to expected privacy to and know, is are committed relevant to the to complying insurer s with decision all applicable whether to privacy accept the laws. risk of These laws insurance and, if include PRIVACY so, PRIVACY on the Privacy what Act 1988, which incorporates the National Privacy Principles for the fair handling of personal terms. information. We respect Your rights to privacy and are committed to complying with all applicable privacy laws. These laws We respect Your rights to privacy and are committed to complying with all applicable privacy laws. These laws include the Privacy Act 1988, which incorporates the National Privacy Principles for the fair handling of personal PRIVACY include the Privacy Act 1988, which incorporates the National Privacy Principles for the fair handling of personal By information. entering into this insurance contract with Us You agree to the collection, use and disclosure of Your personal and We information. respect Your rights to privacy and are committed to complying with all applicable privacy laws. These sensitive information: laws include the Privacy Act 1988, which incorporates the National Privacy Principles for the fair handling of By entering for the primary into this purpose insurance of evaluating, contract with effecting, Us You managing agree to the and collection, administering use and this disclosure or any other of insurance Your personal Cover, and or information. By entering into this insurance contract with Us You agree to the collection, use and disclosure of Your personal and sensitive financial information: sensitive information: service or product provided to You previously, currently or in the future by Us, any related company, or in for conjunction the primary with purpose Us; of evaluating, effecting, managing and administering this or any other insurance Cover, or By entering for the primary into this purpose insurance of evaluating, contract with effecting, Us You managing agree to the and collection, administering use and this disclosure or any other of insurance Your personal Cover, from or to Your insurance intermediary, or from or to Our service providers (including but not limited to lawyers, and or financial service or product provided to You previously, currently or in the future by Us, any related company, or in sensitive financial claims information: service or product provided to You previously, currently or in the future by Us, any related company, or in conjunction consultants with Us; and reinsurers); for conjunction the primary with purpose Us; of evaluating, effecting, managing and administering this or any other insurance Cover, if from we or are to required Your insurance or permitted intermediary, to do so or by from law; or to Our service providers (including but not limited to lawyers, or financial from or to service Your insurance or product intermediary, provided to or You from previously, or to Our currently service or providers in the future (including by Us, but any not related limited company, to lawyers, or about claims Your consultants health, Your and reinsurers); criminal convictions (with the exception of Your spent criminal convictions), membership in conjunction claims consultants with of associations, where Us; and reinsurers); if we are required or permitted appropriate to do and so only by law; for the above stated primary purpose; from if we or are to required Your insurance or permitted intermediary, to do so or by from law; or to Our service providers (including but not limited to for about the Your secondary health, purpose Your criminal of informing convictions You of (with other the products exception and of Your services spent offered criminal by Us, convictions), Our related membership lawyers, claims about Your consultants health, Your and corporations or Your intermediary reinsurers); criminal convictions (with the exception of Your spent criminal convictions), membership of associations, where appropriate and and to only test for and the improve above stated upon the primary insurance purpose; systems used to manage Your if of we associations, are required where or permitted appropriate to do and so only by Policy. law; for the above stated primary purpose; for the secondary purpose of informing You of other products and services offered by Us, Our related about for the Your secondary health, purpose Your criminal of informing convictions You of (with other the products exception and of Your services spent offered criminal by Us, convictions), Our related corporations or Your intermediary and to test and improve upon the insurance systems used to manage membership Your of corporations associations, or Your where intermediary appropriate and and to only test and the improve above stated upon the primary insurance If You do not provide the requested personal information, We may not be able purpose; systems used to manage Your Policy. to evaluate, effect, manage or for Policy. the secondary purpose of informing You of other products and services offered by Us, Our administer Your Cover and You may be breach of Your duty of disclosure. related If You corporations do not provide or Your the intermediary requested personal and to test information, and improve We may upon not the be insurance able to evaluate, systems effect, used to manage manage or Your If You You Policy. do not provide the requested personal information, We may not be able to evaluate, effect, manage or administer administer may access Your Cover Your Cover personal and and information You may be You may be We in in hold breach breach about of Your of Your duty duty by writing of disclosure. of disclosure. to Us or calling Us on 1300 223 782 during office hours, or contact Your intermediary regarding any personal information they may hold about You. We generally If You You do not provide the requested personal information, We may not be able to evaluate, effect, manage provide may the access information personal We information hold free of We charge. hold about You by writing to Us or calling Us on 1300 223 782 during or administer You may access Your Cover personal and information You may be We hold breach about of Your You duty by writing of disclosure. to Us or calling Us on 1300 223 782 during Underwritten office hours, office hours, by or or Guild contact contact Insurance Your Your Limited intermediary intermediary AFSL No.233791 regarding any personal information they may hold about You. We generally regarding any personal information they may hold about You. We generally provide the information We hold free of charge. You provide may the access information personal We information hold free of We charge. hold about You by writing to Us or calling Us on 1300 223 782 Underwritten by Guild Insurance Limited AFSL No.233791 during Underwritten office hours, by or Guild contact Insurance Your Limited intermediary AFSL No.233791 regarding any personal information they may hold about You. We generally

THE INSURED(S) Name of Insured (BLOCK LETTERS) Business Name Business Address Business Registered? Yes No ABN Your Business tax status (% entitlement to Input Tax Credit) Contacts Business Phone ( ) Mobile Phone ( ) Email Website Other Interested Parties Name Address Nature of Interest Period of Cover From: / / To / / at 4.00 pm GENERAL INFORMATION If You answer Yes to ANY of the following please provide details, including dates and amounts in dollars. 1. Have You or any partners or directors of the business: ever been declared bankrupt Yes No ever been involved in a company that became insolvent, or insolvency including administration, liquidation or receivership Yes No ever been convicted of any criminal offence except traffic convictions Yes No 2. Have You in the last 5 years: made an insurance claim for loss, damage or liability Yes No had insurance declined, cancelled or special terms or excess imposed Yes No suffered loss or damage which would have been covered by this insurance Yes No 2

SECTION 1 BUSINESS PROPERTY Insured Interest Sum Insured Sum Insured Building Contents Stock Removal of Debris (replacing automatic limit of the lesser of 50,000 or 20% of Sum Insured) Do You want Mortgage Protection only? (only available for property section) Yes No Yes No Do You want to insure for indemnity conditions (not new for old) Buildings and Contents Yes No Yes No Do You want Flood Cover? Yes No Yes No SECTION 2 BUSINESS INTERRUPTION Interest Insured Sum Insured Sum Insured Gross Profit basis Indemnity period months or Annual Revenue basis Indemnity period weeks Claims Preparation Costs Outstanding Accounts Receivable Additional Increase in Cost of Working Total Sum Insured SECTION 3 THEFT Interest Insured Sum Insured Sum Insured Stock in Trade (excluding tobacco, cigarettes and cigars and liquor, wines and spirits) Tobacco, Cigarettes and Cigars Liquor, Wines and Spirits Contents Other (specify) Total Sum Insured SECTION 4 MONEY Interest Insured Sum Insured Sum Insured Money in transit Money in buildings during business hours Money in buildings outside business hours Money in buildings whilst contained in locked room or strongroom Money at Your or Your employee s residence Do You require Tax Audit Costs cover? Yes No amount 3

SECTION 5 MACHINERY AND ELECTRONIC PLANT PART 1 Machinery Note: Fire and Perils risks are to be insured under Section 1 Business Property Theft risks are to be insured under Section 3 Theft. Do You require cover for: Limit of Indemnity 1. Breakdown of Machinery, Plant, Boilers and Pressure Vessels? Yes No 10,000 2. Deterioration of Refrigerated Goods Yes No Note: i. If Your Machinery answer is Yes, please complete the following list showing the number of each type of equipment at all locations shown on the schedule. ii. Plant must not exceed 4Kw / 5hp. Plant List No. Age Plant List No. Age Air Conditioning Equipment Split System Window / Wall Type Commercial Refrigeration Equipment Freezers / Soft Serve Machine Temprites Other Units Kitchen Equipment Exhaust Fans (incl. Canopy) Microwave Ovens Slicing, Mincing and Mixing equipment Coffee Machine Other Items (please provide details) Laundry Equipment Washers, Extractors, Dryers Misc. Equipment Air Compressor Auto Car Wash Car Hoist Cash Register / Scanning Equipment Engine Diagnostic Unit Pumps (noc) Refrigerant Reclaimer Vacuum Cleaners Wheel Aligner / Balancer Workshop Plant (noc) PART 2 Electronic Plant Note: Fire and Perils risks are to be insured under Section 1 Business Property. Theft risks are to be insured under Section 3 Theft. List items (including make, model and serial numbers) Sum Insured (new replacement cost) Rate % Restoration of Data Additional Increase in Cost of Working Indemnity Period? months Total Sum Insured 4

SECTION 6 BROADFORM LIABILITY Limit of Indemnity 5,000,000 10,000,000 20,000,000 Other How many people including working partners/directors are employed in the business? Gross Annual Wages paid (include commission and other earnings) Annual Turnover Payments made to Sub-Contractors Wages paid to labour hire personnel If You require indemnity as a Property Owner only, please show: 1. Replacement Value of Building 2. Describe all of Your Business operations (including that of Business subsidiaries) Additional Covers available (please show amount when cover required) 1. Property (excluding registered vehicles) in Your physical and legal control (instead of the automatic 100,000) About Your Products (Note Exports to USA / Canada are not covered) 1. Describe fully all products requiring insurance cover and include imported and discontinued products and goods: 2. Do You manufacture, pack or relabel any products which You sell or distribute Yes No If Yes show % Manufacture % Pack % Relabel % 3. Do You import or export products or raw materials? Yes No If Yes, from or to which countries and what are the products? 4. Are Your products required to be manufactured to comply with any Federal or State regulation or recognised International Standard or Code? Yes No If Yes, provide details: SECTION 7 GLASS Interest Insured Internal Glass Yes No Yes No External Glass Yes No Yes No General description of occupancy (ie. factory, warehouse, retail, office) Size of largest pane of Glass m² m² 5

SECTION 8 GENERAL PROPERTY Please indicate which cover is required. Accidental Loss or Damage (standard cover) Yes No Reduced cover Option A (fire, theft, collision and other expressed perils) Yes No (Option A includes only: fire, lightning, explosion, malicious damage or vandalism; theft following forcible and violent entry which causes visible damage to a locked vehicle or premises; theft of equipment, which is securely attached to a vehicle through use of locks or padlocks, which results in visible damage to the securing devices; collision or overturning of the conveying vehicle.) List items (include make, model and serial numbers) for which individual item cover greater than 1,000 is required. Sum Insured Rate % Total Sum Insured Please indicate if Goods in Transit only cover required Yes No Goods in Transit excludes Stock SECTION 9 TRANSIT Insured Property Description Goods Sent (please describe) Value p.a. Estimated Total Sendings Journey details: From: To: Limit of Any One Conveyance required: 5,000 10,000 25,000 Excess Option Premium can be varied based on choices Please indicate Your selection Excess 100 Excess 250 Excess 500 Excess 1,000 Note: When selected these excess amounts apply to all sections of the policy that are operative (except Broadform Liability for bodily injury claims) PLEASE SEE OVERLEAF TO SIGN AND COMPLETE THIS APPLICATION FORM. 6

DECLARATION I/We declare: The statements and particulars given in this Application are true and correct. No information has been withheld that would affect the acceptance of this insurance application or the terms of that acceptance. I/We have read the Important Notices contained in this Application. Guild Insurance Limited may collect or disclose any of the personal information in accordance with the Privacy statement. I/We accept the terms, exclusions, conditions and limitations of the Commercial Insurance Policy. Proposer(s) signatures Dated Insurance broker details Broker firm name Broker contact name Broker address Broker phone number Broker email address FOR OFFICE USE ONLY Cover Note Receipt No. Property Business Interruption Theft Money Machinery Breakdown Electronic Equipment Broadform Liability Glass Transit General Property Premium FSL GST Stamp Duty Total (GLD2121) Commercial Insurance Application 07/15 Guild Insurance Limited AFSL No.233791 7