Business Combined Property Owners

Client Code*

Name of Person completing questionnaire:*

Insured Name:*

1) List of Current Tenants & their Occupations*

2) Have there been any material changes to fire and theft protection alarms, devices and the like during the past 12 months?*

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) Attached to your email is a summary of your existing cover for review. Please advise the changes required.*

Machinery Breakdown

1) The level of cover and sums insured must be reviewed to ensure they are adequate and continue to meet your requirements. Please advise any changes that are required.*

2) Have you installed new machinery / equipment in the last policy period?*

Yes
No

If YES, please advise full details

Property Owner's Liability

1) Estimated Rental Income for the forthcoming year ($)*

2) Number of principals*

3) Number of Staff*

4) Estimated Payroll ($)*

5) Are Contractors/Sub-contractors used?*

Yes
No

Activities performed*

Estimated Annual Payments made: $*

Do you sight current Public Liability insurance prior to work commencing?*

Yes
No

6) Are Labour Hire personnel used?*

Yes
No

Activities performed*

Estimated Annual Payments made: $*

Do you sight current Public Liability insurance prior to work commencing?*

Yes
No

Rental Income / Loss of Earnings

The policy is designed to protect loss of rent in the event of damage to the premises. The following formula will be of help in calculating appropriate values for the forthcoming year. Gross Rental Income for the next 12 months (including special outgoings) $

Do you require quotes for:

Rent Default *

Yes
No

Eviction Costs*

Yes
No

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?*

Yes
No

Claims Declaration

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

2) 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.

Name

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