Business Insurance - Australia Wide. SME and Public Liability Cover - Insurance Brokers Sydney Melbourne Brisbane Adelaide Perth Hobart - Market Stall Insurance

The Activity for which you require Insurance:-

Section 1

		Please tell us more about your activity

If you require cover for more than the limitations above pleasecontact us

If you require cover for more than the limitations above please contact us

What date would you like Cover to start from? - or What is the Expiry Date of your current insurance?		DD / MM / YYYY

Limits of Cover - and Premiums:-

Section 2

Cover Limits		$5 Million	$10 Million	Annual Policy Only -	Public Liability Only

1 to 3	Entertainers	$220	$247	Premium Rates (Includes Stamp Duty)
4 to 6	Entertainers	$300	$355
7 to 10	Entertainers	$450	$505

Note: Entertainers include you and any other person taking part in the insured activity

Standard Claim Excess: $500.00

For more than 10 Entertainers please contact us


Proposer Details -	Section 3

Name :
		Name of person, company or entity seeking insurance
Address :
Suburb :		State : Postcode :
Phone :		Fax :
Email :

Have you or any person associated with this activity ever:-

had a Legal Liability claim made upon you or the other person?

ever made a claim for insurance in respect of the type of cover you require?

been refused insurance?

had an insurance claim of any type refused or reduced?

been charged with a crime of any type?

Depending on your answers to these five questions we may need to contact you for further information


Disclosure and Acknowledgement Details:-	Section 4

Please examine your Duty of Disclosure

Is there anything else you need to disclose to us?

If yes, please write here what it is that you think we ought to know

I acknowledge I have read andI agree to the terms and conditions stated

Credit Card Details:-

Section 5

Your credit card will not be processed until insurance cover is confirmed
Card Type	Please complete the authority below
Cardholder Name
Card Number
Expiry Date	Amount $

Thank you we will do our best to respond in the next few hours - but we may need to contact you for further information