Farm Liability Insurance Form Victoria

Rural Farm & Land Insurance
Including Public Liability Insurance

AUSTRALIAN NATIONWIDE RURAL INSURANCE SERVICES

NSW • VIC • SA • WA • ACT • QLD • NT • TAS

RuralPlus Farm & Vacant Land Public Liability Insurance

PROPOSAL FORM

Public Liability Insurance Only

This proposal is for unoccupied property in NSW Only - If your property is in another State, please
choose other State by clicking here

Please note the following fixed quotations are only availabe on land with a value of $1 Million or less

TYPE OF PROPERTY & USES -

Section 1

Unoccupied Land

Hobby Farm

Working Farm

Other


Is the Property located in:-	a suburb of a City or Town	a Rural Area (not in a suburb of a City or Town)

What is the address of the Property to be insured - and - what size is the property in Hectares

Is any Commercial Enterprise and/or Development carried on at or from the property

If Yes, please tell us about the type of Commercial Enterprise and/or Development carried on

Is any Livestock kept on the property

If Yes, please tell us the type of livestock (cattle, horses, goats etc') and how many of each type (close approximation) and whether or not you own the livestock or if such are agisted

Are any Unregistered Vehicles, such as tractors and/or motor bikes for example, used on the property

Does the property contain any Dams and/or water courses

Structures-Dwellings-Sheds; are they any Structures of such type on the property

If you have answered Yes to the above questions concerning Vehicles - Structures - Dams & Water Courses please provide a general description of such including anything more you need to tell us about the property's uses which you have reason to believe is important for the insurance underwriter to know about


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:- $10 MILLION PUBLIC LIABILITY COVER-

Section 2

Types of Property	up to 4Ha	5 to 50Ha	51 to 200Ha	201 to 500Ha

Unoccupied Land (Suburban location)	$520	$570	$610	$630	Please Select the Cover & Premium Required Premium Rates (Includes Broker Fees & Statutory Charges)
Unoccupied Land (Rural No Livestock)	$530	$580	$630	$640
Unoccupied Land (Rural With Livestock)	$560	$590	$670	$710
Working Farm (Occupied & Livestock)	$580	$590	$680	$720

Standard Claim Excess: $500.00

For Larger Areas or other Uses 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 and I agree to the terms and conditions stated	Your Answer is Mandatory

CREDIT CARD DETAILS - Applications will not be processed without 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 $

Monies will not be deducted from your credit / debit card at this stage. A member of our broking staff will contact you by email or phone to confirm that the Underwriter has accepted your insurance proposal. This should happen within hours of your submission. At that point, the premium quoted will be deducted from your credit / debit card and the formal insurance paper work will be forwarded to you

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

For qualifications concerning the information on this page, please click here.