UIS | Request for Corporate Travel (Obsolete) Quote

Contact Details

Email Address:

Phone Number/Mobile:

Business Details

Business Structure:

Company or Insured Name:

Trading As:

ABN No.:

Registered for GST:

Yes

No

Mailing Address

Address Line 1:

Address Line 2:

Town/Suburb:

Postcode:

State:

Situation at Risk

Business Address

Address Line 1:

Address Line 2:

Town/Suburb:

Postcode:

State:

Insurance History

In the last 5 years have you

i) had insurance refused, cancelled, declined or special terms imposed?

Yes

No

ii) been declared bankrupt, placed in liquidation, receivership or voluntary administration?

Yes

No

iii) been convicted of or had any fines imposed for any crime involving drugs, dishonesty, arson, theft, fraud or violence against any person or property?

Yes

No

If yes to any of the above questions please provide details or phone us to discuss the matter:

Additional Information

Please provide any additional information relevant to your risk, or additional covers you may require:

Would you like to pay monthly?

Yes

No

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