Farm Combined Insurance

Client Code:*

Name of person completing questionnaire:*

Insured Name:*

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

Yes
No

If YES, please advise 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 details

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

Yes
No

If YES, please advise details

Machinery Breakdown

4) The level of cover and sums insured must be reviewed to ensure they are adequate and continue to meet your requirements. So that we can market your renewal please provide a list of all machinery (e.g. 2001 40hp submersible pump, 1997 50hp centrifugal pump, cool room motor).*

5) Have you purchased any machinery / equipment in the last policy period?*

Yes
No

If YES, please advise details

6) Do you have any centrifugal or submersible pumps?*

Yes
No

If YES, please advise details

Liability

7) Estimated Turnover for the forthcoming year ($)*

8) Number of principals*

9) Number of Staff*

10) Estimated Payroll*

11) 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

12) 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

13) Any demolition activities*

Yes
No

Does demolition exceed 3.5 metres in height?

Yes
No

If yes, state maximum height

If yes, percentage of turnover

14) Do you Dry Hire? (Hire out plant without an operator)*

Yes
No

15) Please provide a description of your business activities to ensure your Public Liability cover is sufficient.*

Farm and Private Motor

16) If you Hire-In Plant or Vehicles (including trailers), please advise the estimated maximum duration of each hire and also the highest valued item.*

17) If not already provided in your Policy are you interested in an excess free windscreen cover for an additional premium?*

Yes
No

18) If available, are you interested in covering the hire costs for a similar vehicle following an accident?*

Yes
No

19) Are there any changes in your business activities/operations?*

Yes
No

If YES, please advise details

Driver Disclosures:

20) Please provide details of any person under 25years of age or with less than two (2) years driving experience, that may drive or operate any of the insured units:*

21) Details of any Motor Insurance and/or claims refused and/or cancelled and/or imposed special terms in the last five (5) years:*

22) To the best of your knowledge, details of any convictions for driving under the influence of alcohol or drugs (DUI) and/or exceeding the prescribed content of alcohol (PCA) in the last three (3) years:*

23) To the best of your knowledge, have any employed drivers had a licence suspended or cancelled in the last five (5) years?*

Yes
No

If YES, please provide details

24) To the best of your knowledge, have any employed drivers been convicted of a total of more than two (2) traffic offences (excluding parking) in the last three (3) years?*

Yes
No

If YES, please provide details

Claims

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

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

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

Comments

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Machinery Breakdown

Liability

Farm and Private Motor

Driver Disclosures:

Claims

Sarina Insurance

General Info

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