Statutory Liability Insurance

Statutory Liability

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Your Details		Business		Cover		Disclosure		Declaration

CRM Client ID
N/A
CRM Contact ID
N/A
User Id
N/A
N/A

Send Internal Send Internal
N/A

Send Both Client and Internal Send Both Client and Internal
Internal Email
N/A
Quote Type
N/A
new_quote_id
N/A
Deadline *
N/A

dd/MM/yyyy
Your Details
Are you a prospective new client or an existing client of Business Insurance Specialists Pty Ltd? *
N/A

Prospective Client
Existing Client
a) Is this a Renewal or a Quote for new cover? *
N/A

Renewal
Quote
Expiry Date *
N/A

dd/MM/yyyy
Contact Details
1. Contact Name
N/A

Required First Required Last
2. Phone Number *
N/A

e.g. 02 1234 5678 or 0411 222 333
3. Email Address *
N/A

We will send a copy of your answers immediately to your inbox, and a quotation to you shortly based on full completion of form.
Insured Details
1. Insured Name *
N/A

Legal Entity
2. Trading Name (if applicable)
N/A
3. ABN
N/A

(Website: https://abr.business.gov.au/ to assist)
4. Address
N/A

Required
Street Address Required City Required State / Territory Required
Post Code

	Full-time	Part-time*
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Overseas
TOTAL

	Yes	No
a) Workplace Health & Safety Procedures manual *
b) A manual concerning Protection of the Environment *

	Yes	No
a) A fine or penalty imposed by Federal, State, Local Government or other statutory authority? *
b) Workplace or Environmental incidents that warranted investigation by any Regulatory Authority? *
c) Been required to attend any hearing, inquiry, prosecution or other commission? *

Statutory Liability