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Newsagent Proposal Form
Newsagent Insurance Quote
Insured Details
Full Name:
*
Trading Name:
*
Contact Number:
*
Email:
*
Postal Address:
*
State:
Please select...
ACT
NSW
NT
QLD
SA
TAS
VIC
WA
7483
Postcode:
*
Lotto Outlet No:
*
Details of the Business and Premises
Age of:
Building:
Construction of premises:
Walls:
Roof:
Floors:
Is there any asbestos?
Yes
No
What percentage of the building is foam / EPS construction:
Details of Security
Burglar Alarm
Fire Sprinkler
Smoke Detectors
Windows Bars/Locks
Local Alarm
Fire Hoses
Local Fire Alarm
Deadlocks to external Doors
Back to Base
Fire Alarm
Back to Base Fire
Building and Contents
Value
Buildings:
$
Contents:
$
Stock:
$
Business Interruption
Gross Annual Income:
$
Additional Increased Cost of Working:
$
Indemnity months 12 months or other length:
Burglary (Sums Insured) Cover
All Contents (including stock):
$
Stock Cigarettes & Tobacco:
$
Money (Sums Insured)
In Building – Business Hours:
$
In Building – Out of Business Hours:
$
In Safe or Strongroom:
$
In Transit:
$
Personal Custody:
$
Glass cover
Glass:
Yes
No
General Liability Products Liability
Estimated Annual Turnover:
$
Lotto Earnings:
$
Number of Employees:
Limit Required:
$
Lotto Indemnity $1,000,000 (Included Free)
Number of Staff (including directors/partners) employed in the business:
Provide details of any products you import or export:
Optional Covers
Please Tick if required
Machinery Breakdown
Tax Audit
General Property
Insurance and Claims History
Have you (in the past 5 years)
Made any claim(s) on an insurer for loss or damage?
Yes
No
Had any insurance declined, cancelled, application refused, claim rejected Special
conditions or excess imposed by an insurer?
Yes
No
Suffered any loss or damage which would have been covered by the proposed insurance policy?
Yes
No
Have you or any partner(s)
Ever been declared bankrupt?
Yes
No
Ever been involved in a company or business which became insolvent
or subject to any form of insolvency administration?
Yes
No
Been convicted of any criminal offence within the past 5 years (other than minor traffic offences)?
Yes
No
Been liable for any civil offence or pecuniary penalty?
Yes
No
The Company has not discovered any employee dishonesty, burglary, robbery,
disappearances, destruction or forgery losses?
Yes
No
Declaration
I declare and acknowledge:
that I am, after enquiry, authorised by all person(s) or entities seeking insurance, to make this proposal;
that after enquiry, all information supplied in this proposal and any supporting documents attached to this proposal or supplied separately, is true and correct and I have not withheld any material information from this proposal;
that this proposal and any accompanying documents shall form or partly form the basis of the contract proposed;
that until a Contract of Insurance is entered into, I am obliged to inform the Underwriters of any changes to any information supplied or of any new information that is relevant;
that I understand the Underwriters relies on the accuracy of the information and documentation supplied proposing for this insurance;
that I understand that no insurance is in force until a Contract of Insurance is entered into, which is upon the Proposer’s acceptance of an offer by the Underwriters, if any.
Yes
No
* Indicates a mandatory field.
Submit
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