CycleCover Commercial Liability Proposal

Insured Name(required)

Principal Address(required)

Street Address City State Postcode Country

Additional locations

Telephone No(required)

Email Address(required)

Website Address

Date business established(required)

Are there any Interested Parties required to be noted?(required)

Yes
No

Are you currently insured?(required)

Yes
No

If so, who with….(required)

Please provide a description of your business activities and products supplied

Turnover split by major business activity or product (where the business is conducted in more than one state, we will require a split of turnover by state):(required)

Business Activity	State	Estimated Turnover for the next 12 months

Please provide a turnover % spit per state

VIC	QLD	NSW	TAS	ACT	SA	WA	NT	O/V

Does your business import/export products?(required)

Yes
No

Please provide details

Description of Products	Country	Estimated Turnover

Does your business have a written policy for the following

Risk Management
Bike Hire Disclaimer
Maintenance Schedule

If YES, please attach

Drop files here or

Accepted file types: pdf, jpg, png, doc, docx, Max. file size: 2 MB.

Have any claims been made in the last 5 years?(required)

Yes
No

If YES, please provide details(required)

Has any insurer ever declined, refused to renew, or has imposed special terms and conditions to any insurance policy/renewal or application for insurance held by your business?(required)

Yes
No

If YES, please provide details(required)

Limit of Liability required(required)

$5,000,000
$10,000,000
$20,000,000

Policy Start Date(required)

Additional Comments

Name

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