Business Combined Pre Renewal Form - Steel Pacific Insurance Brokers

Step 1 of 3

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Which office branch sent you this form?(Required)

Sarina

Ingham

Mackay

Maroochydore

Townsville

Proserpine

Ian Hayes

Please select only one.

Name of Insured

Name

Renewal Disclosures

Estimated turnover for the forthcoming year

Estimated Cost of Goods Sold for the forthcoming year

Number of Principals?

Number of Employees?

Number of Labour Hires?

Number of Sub-Contractors?

Number of Payments to labour hire / sub-contractors?

Undisclosed Claims

Details of any claims that have occurred, but have not yet been reported

After specific inquiry, details of any facts, circumstances or incidents (other than those already disclosed, notified to your insurer) which could give rise to a future claim.

Other Insurances

Are there any other insurance needs e.g. Insurance of Income, Home, Contents, Motor Vehicle, Caravan, Boat etc, with which we can assist?

Untitled

Duty of disclosure

All questions are mandatory.

Has any insurer in respect of any insurance policy held by you, your partners and/or directors (incl. shadow directors) ever:

a) Refused to renew / cancelled or terminated a policy?(Required)

Yes

b) Refused a claim or required an increased premium under the policy?(Required)

Yes

c) Imposed special conditions under the policy?(Required)

Yes

Have you, your partners and/or directors (incl. shadow directors):

a) in the past ten (10) years, been convicted of any criminal offence?(Required)

Yes

b) in the past ten (10) years, been declared bankrupt?(Required)

Yes

c) in the past years (5) years, had any claims?(Required)

Yes

If 'Yes' to any of the above, provide details:

Name of person who completed the form(Required)

First Last

Your email(Required)

Number(Required)

Pre Renewal - Business Combined

Name of Insured

Renewal Disclosures

Undisclosed Claims

Other Insurances

Duty of disclosure

Steel Pacific Insurance Brokers

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