Bottleshop Insurance - Online Networksteadfast

Insured Name*
ABN*
Postal Address*
Street Address City State Postcode
Contact Person*
First Name Surname
Position
Email*
Phone or Mobile*
Number of Years in Business

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In the last five (5) years have you:
Made any claim(s) for loss or damage?*
- Yes
- No
Had any insurance declined or cancelled, application rejected, renewal refused, claim rejected, special conditions or excess imposed by any insurer?*
- Yes
- No
Suffered any loss or damage which would have been covered by the proposed insurance policy?*
- Yes
- No
If Yes to any of the above, please complete the below table
Date of Incident Description of Incident Value of Loss ($) Insurer Name
Have you or any partner(s), shareholder(s) or director(s) of the business:
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 (e.g. liquidation or receivership)?*
- Yes
- No
Been convicted of any criminal offence within the past five (5) years (other than minor traffic convictions)?*
- Yes
- No
Been liable for any civil offence or pecuniary penalty exceeding $5,000?*
- Yes
- No
If Yes to any of the above, please provide full details below

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Check the Cover limits that your interested in*
- Property
- Business Interruption
- Theft/Burglary
- Glass
- Money
- Machinery Breakdown
- General Property
Property
Insured Amount
Building - Including landlords fixtures & fittings
Contents
Stock
Do you require Flood cover?
- yes
- No
Business Interruption
Insured Amount
Indemnity Period - Months
Annual Rent Receivable
Annual Insurable Gross Profits (turnover minus cost of sales)
Optional Extensions
Claims Preparation Costs
- Yes
- No
Additional Increased Costs of Working
- Yes
- No
Accounts Receivable
- Yes
- No
Costs of Rewriting Records
- Yes
- No
Theft/Burglary
Insured Amount
Stock, excluding tobacco, cigars and/or cigarettes
Contents, excluding money
Tobacco, cigars and/or cigarettes
Optional Extensions
Theft without forcible Entry*
- Yes
- No
Description of items to be insured
Theft of items in the Open Air*
- Yes
- No
Description of items to be insured
Glass
Is Glass cover required?*
- Yes
- No
Money
Insured Amount
Money on the premises during business hours, whilst in transit or contained in a locked safe/strongroom or in an ATM
Money on the premises outside of business hours
Money in Private Residence
Damage to safe/strongroom
Machinery Breakdown
Option 1 - Blanket Cover
Blanket Cover
- Yes
- No
Number of machines to be covered
Maximum Sum Insured any one event/loss
Option 2 - Specific Cover
List Items to be insured with description and replacement cost:
Items Price - $
Deterioration of Refrigerated Stock
- Yes
- No
List all
Items Price - $
General Property
Type of Cover
- Accidental Loss or Damage (standard cover)
- Reduced Cover Option - Fire. Theft, Collision & Expressed Perils
Blanket Cover - Items under $1,000 only
Number of items to be covered
Sum Insured
- $5,000
- $10,000
- $15,000
- $20,000
Specified Items
List Items to be insured with description and replacement cost:
Items Price - $

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Duty Of Disclosure
Under the Insurance Contracts Act 1984 (the Act); you have a Duty of Disclosure. You are required before you enter into, renew, vary, extend or reinstate your Policy, to tell your insurer everything you know that a reasonable person in the circumstances could be expected to know, is a matter that is relevant to the insurer’s decision whether to accept the risk of insurance and, if so, on what terms.

Your duty, however, does not require disclosure about 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 his business ought to know
- as to which compliance with your duty is waived by the insurer
Non-Disclosure
If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce their liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning.

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Average or Co-Insurance
A co-insurance (average) clause applies to the Property, Business Interruption & Electronic Equipment sections of this policy.

This means that if the Sum Insured for any items of Property insured under the Property Section; or the Gross Income insured under the Business Interruption section; or any item of Electronic Equipment insured under the Electronic Equipment section is less than 80% of its value at the time you take out the Policy and at each renewal, your claim will be reduced in proportion to the amount of underinsurance.

The application of co-insurance is in accordance with the following formula:
Sum Insured x Amount of Loss or Damage ÷ 80% of value = Amount Payable

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Declaration
I hereby declare that:
1. I am authorised to complete this form on behalf of the Insured referred to in Question 1; and
2. All answers to the questions contained in this form and all attachments including supplementary questionnaires, are true, correct and complete and that no material facts have been misstated, omitted or suppressed; and
3. I have diligently made all necessary and detailed enquiries in order to comply with the Duty of Disclosure; and
4. I understand that, up until a contract of insurance is entered into, I am under a continuing obligation to immediately inform the Insurer of any change in the particulars or statements contained in this form or accompanying documents.
Print Name*
Date*
DD slash MM slash YYYY
Signature*
Comments
This field is for validation purposes and should be left unchanged.

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Bottleshop Insurance Proposal

Step 1 of 7 - Applicant Details

In the last five (5) years have you:

Have you or any partner(s), shareholder(s) or director(s) of the business:

Construction of Premises

Fire Protection

Security Protection

Property

Insured Amount

Business Interruption

Insured Amount

Optional Extensions

Theft/Burglary

Insured Amount

Optional Extensions

Glass

Money

Insured Amount

Machinery Breakdown

Option 1 - Blanket Cover

Option 2 - Specific Cover

General Property

Blanket Cover - Items under $1,000 only

Specified Items

Duty Of Disclosure

Non-Disclosure

Average or Co-Insurance

Declaration

Date of Incident	Description of Incident	Value of Loss ($)	Insurer Name

Items	Price - $

Items	Price - $

Items	Price - $