First Name: *
Surname: *
Business Name: *
Email: *
Phone: *
Mailing Address
Address: *
Suburb: *
State:
Postcode:  *
Machine Details
Type Number Value $
1.
2.
3.
4.
Attach Machine List:
Where will the machines be located:
Arcades
Construction Sites
Depots
Factories/Mechanics
Office Buildings
Retail/Food shops
Schools
Shopping Centres
Train Stations
Other
Are any Machines located outdoors: Yes  No
Have you had any claims (insured or not) on your machines in the past 5 years: Yes  No
If yes, Please provide details:
How long have you been operating your vending business?
When do you require the insurance to start? Click here to open the calendar
* Indicates a mandatory field.