Political Risk Insurance

CRM Client ID

CRM Contact ID

User Id

Send Internal

Send Both Client and Internal

Internal Email

Quote Type

new_quote_id

Deadline

dd/MM/yyyy

Expiry Date *

dd/MM/yyyy

Contact Details

1. Contact Name

First Last

2. Phone Number *

e.g. 02 1234 5678 or 0411 222 333

3. Email Address *

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 (Legal Entity to be insured) *

2. Trading Name (if applicable)

3. ABN

(Website: https://abr.business.gov.au/ to assist)

4. Address

Street Address City State / Territory Post Code

1. Name of Financier *

MOF: MOF is Ministry of Finance. A MOF g’tee essentially means that the state is taking the liability onto their balance sheet, and is monitored by the IMF. From the insurer’s perspective, this means they are taking sovereign rather than private risk, because the risk is non-honouring of the MOF g’tee.

MOF Guarantee *

Security Position: Security position taken by the financier refers to their position in the capital structure, i.e. Is the loan secured/unsecured, and if secured what charge are they taking over the assets?

Financier Security Position *

4. Details of physical asset

Tenor *

Other Insurer *

Expiry Date *

dd/MM/yyyy

Start Date

dd/MM/yyyy

Important Notice

You agree that you understand the statutory notices below by doing any of the following:

Signing and submitting this form; or
Providing response to information requested; or
Providing us with instructions to place the policy.

Click here to read our Duty of Disclosure, Financial Services Guide and Privacy Notices.

Please advise that this type of insurance is ‘Claims Made’ rather than ‘Occurrence based’.

Tick to confirm that you have read the above documents or will prior to commencing coverage. *

Full Name

First Last

Position held *

Date Signed *

dd/MM/yyyy

Please advise referrer's name so we can thank them. *

Other - Please provide details. *

Other Insurances *

Quote Source

Political Risk Insurance

Your Details

Cover Details

Declaration

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Form Summary

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