Business Combined Insurance Form (BI)

Client Code*

Name of person completing questionnaire*

Insured Name*

Business Combined Insurance

1. Are there any changes in your business activities / operations?*

Yes
No

If YES, please advise full details

2. Have there been any material changes to fire and theft protection alarms, devices and the like during the past 12 months? (e.g. disconnection or dismantling or installation of any services)*

Yes
No

If YES, please advise full details

3. Is there any history of flood damage at the insured location(s)?*

Yes
No

If YES, please advise full details

4. Is there any history of flood damage at any of your key suppliers' premises?*

Yes
No

If YES, please advise full details

5. Is there any history of flood damage at any trade show or exhibition ground where you display goods?*

Yes
No

If YES, please advise full details

Business Interruption/Loss of Earnings

The policy is designed to protect loss of earnings and it is important to adjust Business Interruption values at each renewal.

The following formula will be of help in calculating appropriate values for the forthcoming year.

Estimated Sales ($)

Less ( - ) Purchases (Cost of goods $)
Equals ( = ) Insurable Gross Profit

OR

Gross Rental Income for next 12 months (including special outgoings $)

Select your calculation method*

Estimated Sales
Gross Rental Income

Estimated Sales*

Minus Purchases (Cost of goods)*

Equals Insurable Gross Profit*

Gross Rental Income for next 12 months (including special outgoings $)*

6. Do you require quotes for Rent Default?*

Yes
No

7. Do you require quotes for Eviction Costs?*

Yes
No

Claims

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

9. 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*

All changes or inclusions of any sort or type, including limits or sums insured shown, will take effect from the policy's expiry date unless you request otherwise.

Information we have provided to Sarina Insurance Brokers, is to the best of our knowledge correct. Please type your name below:*

Name

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