Commercial Insurance Application

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Commercial Insurance Application

IMPORTANT NOTICE RELATING TO THIS APPLICATION

Please read this section before you complete the Application.

HOW TO CONTACT ACERTA: enquiries@acerta.com.au Ph: 1300 223 782

DUTY OF DISCLOSURE

Under the Insurance Contracts Act 1984, You have a duty of disclosure. This means before You enter into a contract of general insurance with an insurer, You have a 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 so, on what terms.

You have the same duty to disclose those matters to the insurer before You renew, extend, vary or reinstate a contract of general insurance.

Your duty does not require disclosure of any matter:

• that diminishes the risk to be undertaken by the insurer;

• that is of common knowledge;

• that Your insurer knows or, in the ordinary course of its business, ought to know;

• as to which compliance with Your duty is waived by the insurer. NON-DISCLOSURE

PRIVACY

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 information.

By entering into this insurance contract with Us You agree to the collection, use and disclosure of Your personal and sensitive information:

• for the primary purpose of evaluating, effecting, managing and administering this or any other insurance Cover, or financial service or product provided to You previously, currently or in the future by Us, any related company, or in conjunction with Us;

• from or to Your insurance intermediary, or from or to Our service providers (including but not limited to lawyers, claims consultants and reinsurers);

• if we are required or permitted to do so by law;

• about Your health, Your criminal convictions (with the exception of Your spent criminal convictions), membership of associations, where appropriate and only for the above stated primary purpose;

• for the secondary purpose of informing You of other products and services offered by Us, Our related

corporations or Your intermediary and to test and improve upon the insurance systems used to manage Your Policy.

Commercial Insurance Application

DUTY OF DISCLOSURE

PRIVACY

Commercial Insurance Application

DUTY OF DISCLOSURE

PRIVACY

If You do not provide the requested personal information, We may not be able to evaluate, effect, manage or administer Your Cover and You may be in breach of Your duty of disclosure.

You may access personal information We hold about You by writing 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

YOUR DUTY OF DISCLOSURE

Before You enter into an insurance contract, You have a duty to tell Us anything that You know, or could reasonably be expected to know, may affect Our decision to insure You and on what terms. You have this duty until We agree to insure You. You have the same duty before You renew, extend, vary or reinstate an insurance contract.

You do not need to tell Us anything that:

• reduces the risk We insure You for; or

• is common knowledge; or

• We know or should know as an insurer; or

• We waive Your duty to tell Us about.

IF YOU DO NOT TELL US SOMETHING

If You do not tell Us anything You are required to, We may cancel Your contract or reduce the amount We will pay You if You make a claim, or both. If Your failure to tell Us is fraudulent, We may refuse to pay a claim and treat the contract as if it never existed.

Commercial Insurance Application

DUTY OF DISCLOSURE

PRIVACY

Commercial Insurance Application

DUTY OF DISCLOSURE

PRIVACY

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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

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SECTION 1 – BUSINESS PROPERTY

Insured Interest Sum Insured Sum Insured

Location 1 Location 2

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 InsuredLocation 1 Sum InsuredLocation 2 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 InsuredLocation 1 Sum InsuredLocation 2 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 InsuredLocation 1 Sum InsuredLocation 2

Money in transit $ $

Money in buildings during business hours $ $

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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 Laundry Equipment

Split System Washers, Extractors, Dryers

Window / Wall Type Misc. Equipment

Commercial Refrigeration Equipment Air Compressor

Freezers / Soft Serve Machine Auto Car Wash

Temprites Car Hoist

Other Units Cash Register / Scanning Equipment

Kitchen Equipment Engine Diagnostic Unit

Exhaust Fans (incl. Canopy) Pumps (noc)

Microwave Ovens Refrigerant Reclaimer

Slicing, Mincing and Mixing equipment Vacuum Cleaners

Coffee Machine Wheel Aligner / Balancer

Other Items (please provide details) 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

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SECTION 6 – BROADFORM LIABILITY

Limit of Indemnity $5,000,000 $10,000,000 $20,000,000 Other $ _________________

Location 1 Location 2

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 Location 1 Location 2

Internal Glass _{Yes No} _{Yes No}

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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)

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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. ________________________

Premium FSL GST Stamp Duty Total

Property

Business Interruption Theft

Money