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Proposal Form – Business Insurance

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General Information

General Information List*

Name of the proposer(s) to be covered

Trading Name

Date Established

ABN*

GST registered*

Yes

No

Date registered from*

DD slash MM slash YYYY

Contact Person*

Phone

Designation of person*

Email*

Postal Address*

Business Address*

Existing Business?*

Yes

No

Current Insurance Policy*

Expiry Date

MM slash DD slash YYYY

Renewal Offered?

Period of Insurance required

Start Date

MM slash DD slash YYYY

Expiry Date

MM slash DD slash YYYY

Occupation Details (Full Description)*

Years in Operation

Estimated Turnover

Split of Turnover per state (%)

ACT

NSW

NT

QLD

SA

TAS

VIC

WA

Public & Product Liability Cover

Public Liability Cover Required?*

Yes

No

Public Liability – Limit of liability Required*

Estimated Wages for people working in the business (Staff)*

Number of people working in the business (Staff)*

Do you import?*

Yes

No

Do you export?*

Yes

No

Sub-Contractors

Do you engage Sub-Contractors?*

Yes

No

Payment Annually to Sub-Contractors*

Activities conducted by Sub-Contractors*

Labour Hire Personnel

Do you engage Labour Hire Personnel?*

Yes

No

Payment Annually to Labour Hire Personnel*

Activities conducted by Labour Hire Personnel*

Interested Parties

Interested Parties List*

Name

Interest Type

Other Information

Building Information

Occupancy*

Locality (shopping centre, industrial estate, main rd. etc.)*

Is the building free of asbestos material?*

Building Construction

Floor Material*

Wall Material*

Roof Material*

Year Built*

Fire Protection and Prevention

Smoke Detectors*

Yes

No

Hose Reels*

Yes

No

Fire Hydrants*

Yes

No

Sprinklers*

Yes

No

Fire Blankets*

Yes

No

Other

Security Protection

Bollards*

Yes

No

Deadlocks Fitted*

Yes

No

CCTV*

Yes

No

Windows Security

Key Lock

Grill

Shutter

Fixed Glass

Door Security

Single Key Lock

Double Key Lock

Security Door

Alarm System*

Yes

No

Monitored By

Secure Line*

Yes

No

Phone Line*

Yes

No

Patrolling*

Yes

No

Other

Fire and Other damage Cover

Fire and Other damage Cover Required*

Yes

No

Building

Contents ($)

Stock ($)

What percentage of the building floor area is enclosed by or contains EPS or Insulated sandwich panelling?

Business Interruption Cover

Business Interruption Cover Required*

Yes

No

GROSS PROFIT

Annual Gross Profit ($)

Indemnity Period Required (Months)

Gross Profit Sum Insured ($)

GROSS PROFIT

Annual Gross Rentals ($)

Indemnity Period (Months)

Gross Rentals Sum Insured ($)

OPTIONAL INSURANCE

Claims Preparation Costs Required*

Yes

No

Cover amount required ($)

Additional Increased Costs of Working*

Yes

No

Cover amount required ($)

Account Receivable Required*

Yes

No

Cover amount required ($)

Burglary / Theft Cover

Burglary / Theft Cover Required*

Yes

No

Stock ($)

Contents ($)

Cigarettes, Cigars and Tobacco ($)

Liquor ($)

General Property Cover

General Property Cover Required?*

Yes

No

List

Type (e.g. Laptop / Notebook computer)

Description (e.g. Samsung intel core i7 …)

Sum Insured (e.g. $1,500)

Glass Cover Required?*

Yes

No

Please provide sublimit for signage ($)

Fraud and Dishonesty Cover

Fraud and Dishonesty Cover Required*

Auto

Manual

Overall limit for all employees ($)

Number of Employees

Limit per employee ($)

Money Cover

Money Cover Required*

Yes

No

Money on Premises*

During business hours ($)

Outside business hours ($)

In locked safe / strongroom ($)

Money in transit ($)

Money at Private Residence ($)

Machinery Breakdown

Machinery Breakdown Required*

Yes

No

Repair or Replace

Yes

No

Amount ($)

Air Conditioning Unit Cover Required?*

Yes

No

Unspecified Machinery – Per unit limit apply

Cool Rooms – Number of Units

All other – Number of Units

Specified Machinery

Type

Description

Year Old

Sum Insured

Service Frequency

OPTIONAL INSURANCE

Deterioration of Stock ($)

Restoration of Computer Data ($)

Substitute Computer Systems ($)

Electronic Breakdown

Electronic Breakdown Required*

Yes

No

Amount ($)

Specified Machinery

Type

Description

Year Old

Sum Insured

Service Frequency

Increased Cost of Working ($)

Restoration of Computer Data ($)

Goods in Transit Cover

Goods in Transit Cover Required*

Yes

No

Total Turnover ($)

Limit any one load ($)

Refrigerated Goods*

Yes

No

Description of Goods

Information: Specified perils are fire, flood, theft, collision, and overturning. Please refer to PDS for further details

Type of cover

Option A – Loss or damage by specified perils

Option B – Loss or damage by unspecified perils

Management Liability Cover

Management Liability Cover Required

Yes

No

Limit of Liability ($)

Number of employees

Optional cover – Employee dishonesty ($)

Motor Vehicles Cover

Motor Vehicles Cover Required

Yes

No

Motor Vehicles Cover - Vehicle Details

Vehicle: Make, Model

Year

DD slash MM slash YYYY

Registration Number

VIN

Engine No.

Market Value

Vehicle Body

Name of Driver

Date of Birth of Driver

DD slash MM slash YYYY

License suspended ever?

Yes

No

Any Loan on Vehicle

Yes

No

If Yes, Finance Co. Name

Add more

Previous Insurer Details

Name of Previous Insurer

At Fault

Yes

No

Incurred Claims $

No. of Vehicles

Add more

Past Business Insurance Claim History

Any Past Business Insurance Claim History

Yes

No

Past Business Insurance Claim History Details

Date of Loss

DD slash MM slash YYYY

Circumstances / Details of Loss

Insurer

Amount Paid / Outstanding

Add more

Duty Of Disclosure

Has any Insurer declined a proposal from you, or cancelled or refused to renew a policy of yours, or imposed special terms on your insurance?*

Yes

No

N/A

Have you, in the last 5 years, suffered or claimed for any loss or damage to property*

Yes

No

N/A

How many claims?

Have you, in the last 5 years, received any demand or writ for personal injury or damage to property?*

Yes

No

N/A

How many claims?

Have you or any person, in the last 10 years, who will receive insurance protection under the proposed policy, been charged or convicted of any criminal offence relating to arson, drugs, burglary, housebreaking, theft, robbery, receiving stolen goods, fraud, dishonesty of any kind, malicious damage, damage to property, injury or assault to anyone?*

Yes

No

N/A

Date of latest occurrence?

DD slash MM slash YYYY

In the last 12 months, have you been bankrupt, had a receiver appointed or had an administrator appointed?*

Yes

No

N/A

Date of latest occurrence?

MM slash DD slash YYYY

Has any insurer declined or refused a claim?*

Yes

No

N/A

If YES to any of the above, please provide details

Signature*

Name*

On Behalf of*

Date*

DD slash MM slash YYYY

Home
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About Us
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Contact Us

Home
Insurance
Industries
Claims
Proposals
About Us
FAQs
Privacy Policy
Contact Us

Protecting your future with tailored insurance solutions.

Contact Us

03 8401 3318
admin@biima.com.au

Service Area

Australia Wide

Disclosure: G N Insurance Pty Ltd T/As BIIMA (CAR No. 1233580 | ABN: 15 604 013 523)
Corporate Authorise representative of Community Broker Network Pty Ltd | AFSL 233750 | ACN 096 916 184)

Insurance

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First Name(Required)

Last Name

Phone Number(Required)

Email(Required)

Type of Insurance Needed(Required)

Type of insurance needed (if other)

Further Details

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Step 1 of 5

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Do you have an existing business?*

Yes

No

If Existing Business

Number of years business in operation*

Current Insurance Company Name*

Current Policy Expiry date*

DD slash MM slash YYYY

Any motor claim history in last 5 years*

Yes

No

Insured Details

Name*

ABN*

Business Address*

Postal Address*

Phone Number*

Email*

Contact Person*

Director/ Owner

Director/Driver Name*

Date of Birth*

MM slash DD slash YYYY

Licence Type and Year Licence Obtained*

Driving Experience*

Policy

Start Date Requested*

DD slash MM slash YYYY

Finish Date Requested

DD slash MM slash YYYY

Business Activities (Advise if Refrigerated carting included)*

Age of Youngest Driver?*

Any driver with less than 2 years of driving experience?*

Yes

No

Any driver had his/her licensed cancelled or suspended within the last 5 years?*

Yes

No

Estimated Turnover (for next 12 months)

Public Liability Cover Required?*

Yes

No

Cover amount

Marine Cargo (M.C.) Cover Required.*

Yes

No

Cover amount

Number of Vehicles M.C. required for.

Downtime Cover Required?*

Yes

No

Number of weeks required

Number of Vehicle required

Limit required for each vehicle. Per week

Truck Details

Registration Number*

State of Registration*

Year*

Truck: Make & Model*

Truck: Body Type*

Truck: Payload Or GVM*

Refrigerated?*

Yes

No

VIN*

Engine No.*

Transmission Type*

Auto

Manual

Sum Insured Required*

What you carry?*

No. of claims on this vehicle*

DG Sum Insured Required*

Registered Owner*

Trailer In Control (TIC) Reqd:*

Yes

No

TIC Sum Insured (Truck)*

Garage Postcode*

Radius (in Kms)*

Any Loan?*

Yes

No

Interested Party Name*

Add more

Duty Of Disclosure

Has any owner/director or officer of the business ever been declared bankrupt or been involved with a business that has gone into receivership, or liquidation in the last 5 years?*

Yes

No

N/A

Has any owner/director or officer of the business, or the business itself had any insurance policy cancelled, declined or refused in the last 5 years?*

Yes

No

N/A

Has any owner/director or officer of the business, or the business itself been convicted of a criminal offence in the last 10 years?*

Yes

No

N/A

In the past 5 years have your or any of your drivers had any license suspended, cancelled, or amended to provisional; Or any alcohol or drug conviction; Or any dangerous driving offence; Or any offence involving with a speed limiter?*

Yes

No

N/A

In the past 5 years, how many speeding offences > 15kph in a heavy vehicle or Red-Light Offences you or any of your drivers have received?*

Yes

No

N/A

Is any Motor Vehicle lent out, leased out, or control assigned to any other party (ie. Dry Hired)?*

Yes

No

N/A

Do you or any of your driver have a physical or mental ailment/condition that detracts from your driving ability?*

Yes

No

N/A

Do you perform any high-risk activities?*

Yes

No

N/A

Had any insurance declined, cancelled, refused or special conditions/terms imposed, or claim refused?*

Yes

No

N/A

Had any convictions which are less than 10 years old (adult), 5-year-old (juvenile), or if outside of these years any convictions that have had a prison sentence greater than 30 months?*

Yes

No

N/A

Previous Insurance Company?*

Yes

No

N/A

Signature*

Name*

On Behalf of*

Date*

DD slash MM slash YYYY

×

Get acquainted, explore market-leading business insurance solutions and find the right fit.

"*" indicates required fields

Step 1 of 5

20%

Do you have an existing business?*

Yes

No

If Existing Business

Number of years business in operation*

Current Insurance Company Name*

Current Policy Expiry date*

DD slash MM slash YYYY

Any motor claim history in last 5 years*

Yes

No

Insured Details

Name*

ABN*

Business Address*

Postal Address*

Phone Number*

Email*

Contact Person*

Director/ Owner

Director/Driver Name*

Date of Birth*

MM slash DD slash YYYY

Licence Type and Year Licence Obtained*

Driving Experience*

Policy

Start Date Requested*

DD slash MM slash YYYY

Finish Date Requested

DD slash MM slash YYYY

Business Activities (Advise if Refrigerated carting included)*

Age of Youngest Driver?*

Any driver with less than 2 years of driving experience?*

Yes

No

Any driver had his/her licensed cancelled or suspended within the last 5 years?*

Yes

No

Estimated Turnover (for next 12 months)

Public Liability Cover Required?*

Yes

No

Cover amount

Marine Cargo (M.C.) Cover Required.*

Yes

No

Cover amount

Number of Vehicles M.C. required for.

Downtime Cover Required?*

Yes

No

Number of weeks required

Number of Vehicle required

Limit required for each vehicle. Per week

Truck Details

Registration Number*

State of Registration*

Year*

Truck: Make & Model*

Truck: Body Type*

Truck: Payload Or GVM*

Refrigerated?*

Yes

No

VIN*

Engine No.*

Transmission Type*

Auto

Manual

Sum Insured Required*

What you carry?*

No. of claims on this vehicle*

DG Sum Insured Required*

Registered Owner*

Trailer In Control (TIC) Reqd:*

Yes

No

TIC Sum Insured (Truck)*

Garage Postcode*

Radius (in Kms)*

Any Loan?*

Yes

No

Interested Party Name*

Add more

Duty Of Disclosure

Has any owner/director or officer of the business ever been declared bankrupt or been involved with a business that has gone into receivership, or liquidation in the last 5 years?*

Yes

No

N/A

Has any owner/director or officer of the business, or the business itself had any insurance policy cancelled, declined or refused in the last 5 years?*

Yes

No

N/A

Has any owner/director or officer of the business, or the business itself been convicted of a criminal offence in the last 10 years?*

Yes

No

N/A

In the past 5 years have your or any of your drivers had any license suspended, cancelled, or amended to provisional; Or any alcohol or drug conviction; Or any dangerous driving offence; Or any offence involving with a speed limiter?*

Yes

No

N/A

In the past 5 years, how many speeding offences > 15kph in a heavy vehicle or Red-Light Offences you or any of your drivers have received?*

Yes

No

N/A

Is any Motor Vehicle lent out, leased out, or control assigned to any other party (ie. Dry Hired)?*

Yes

No

N/A

Do you or any of your driver have a physical or mental ailment/condition that detracts from your driving ability?*

Yes

No

N/A

Do you perform any high-risk activities?*

Yes

No

N/A

Had any insurance declined, cancelled, refused or special conditions/terms imposed, or claim refused?*

Yes

No

N/A

Had any convictions which are less than 10 years old (adult), 5-year-old (juvenile), or if outside of these years any convictions that have had a prison sentence greater than 30 months?*

Yes

No

N/A

Previous Insurance Company?*

Yes

No

N/A

Signature*

Name*

On Behalf of*

Date*

DD slash MM slash YYYY

×

Get acquainted, explore market-leading business insurance solutions and find the right fit.

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

This questionnaire should be completed in conjunction with the ISP Proposal Form. When completed, please sign this questionnaire where indicated, ensuring that prior to signing you have read and understand Your Duty of Disclosure and our Privacy statement.

Section A: General Information

Date

DD slash MM slash YYYY

Years in Business

Policy No.

Insured Name

Insured Email*

Suburb

Postcode

Section B: Machines to be insured

The age of the pumping unit must be supplied

Truck

Truck details

Year / age

Description of units (make/model)

Rego

Sum Insured

Add more

Pump

Pump Details

Year / age

Description of units (make/model)

Rego

Sum Insured

Add more

Section C: Maintenance And Accreditation

Who undertakes maintenance / servicing of concrete pumping machines?

External Service Providers.

Yes

No

In House by Your Own Employees.

Yes

No

How often does maintenance/servicing take place?

Are all your concrete pumping machines certified in accordance with Australia Standard AS2550 and/or AS2550.15?. If no, provide reasons why in space provided

Yes

No

Reasons

Section D: Claims and/or circumstances

Who undertakes maintenance / servicing of concrete pumping machines?

File

Drop files here or

Max. file size: 100 MB.

Claims and/or circumstances list

Year

Claim Details

Incurred

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.

QBE Privacy

We will collect personal information when you deal with us, our agents, other companies in the QBE group or suppliers acting on our behalf. We use your personal information so we can do business with you, which includes issuing and administering our products and services and processing claims. Sometimes we might send your personal information overseas. The locations we send it to can vary but include the Philippines, India, Ireland, the UK, the US, China and countries within the European Union.

Our Privacy Policy describes in detail where and from whom we collect personal information, as well as where we store it and the full list of ways we could use it. To get a free copy of it please visit qbe.com.au/privacy or contact QBE Customer Care.

It’s up to you to decide whether to give us your personal information, but without it we might not be able to do business with you, including not paying your claim.

UAA Privacy

UAA is committed to protecting the privacy of personal information in accordance with the Privacy Act 1988 (Cth). UAA’s privacy principles, set out at www.uaa.com.au, explain what personal information is collected from the Insured, why it is collected, how it will be used and to whom it can be disclosed

Declaration

Please remember we will treat a statement or claim or an act or omission by any one of the applicants as a statement or claim or an act or omission by all of the applicants.

I/ We have received a copy of the Policy wording QM2003
I/We declare that all answers and statements made in the application are true, correct and complete in every respect.

Signature

Signature of applicant

Add more

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Get acquainted, explore market-leading business insurance solutions and find the right fit.

General Information

Full Insured Name

Trading Name

ABN

Are you a Licensed Real Estate Agent or an Authorised Rep. of a Licensed Real Estate Agent?

Contact Person

Phone

Designation of the person providing information

Main Office Address

Postal address

Address of any branch or office

Office Phone

Email

Web Address

Do you have Professional Indemnity insurance policies?

Yes

No

Policy Expiry Date

DD slash MM slash YYYY

Sum Insured

Do you have Public Liability insurance policies?

Yes

No

Policy Expiry Date

DD slash MM slash YYYY

Sum Insured

Do you have Management Liability insurance policies?

Yes

No

Policy Expiry Date

DD slash MM slash YYYY

Sum Insured

Has the firm, any partner, principal or director ever been refused this type of insurance, had special terms imposed, had a policy cancelled or had an application for renewal declined?

Yes

No

Please Provide full Details

Privacy Policy

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