Liability Insurance

Public and Products Liability Insurance

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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
N/A

If any of the above are not applicable to you, please click here. If any of the above are not applicable to you, please click here.
Please select any of the below industry Liability forms if they are applicable to you.
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 (Legal Entity to be insured) *
N/A
2. Trading Name (if applicable)
N/A
3. ABN
N/A

(Website: https://abr.business.gov.au/ to assist)
x3. ABN
N/A

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

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

	Yes	No
a) Had an insurance policy cancelled, declined or terms imposed? *
b) Been declared bankrupt? *
c) Been involved in a company which became insolvent or subject to any form of insolvency or voluntary administration (eg. liquidation/ receivership)? *
d) Been convicted of any criminal offence within the past 5 years (other than minor traffic convictions)? *
e) Been liable for any civil offence or pecuniary penalty (exceeding $5,000)? *

Public and Products Liability Insurance