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Quote Form Plant And Equipment (Obsolete)
Contact Details
Situation at Risk
Employees
Import / Export
Vehicle Details
Activities
Insurance History
Additional Information
Contact Details
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Contact Person:
Email Address:
Phone Number/Mobile:
Business Details
Business Structure:
Company
Incorporated Association
Other
Partnership
Personal
Private Company (Pty Ltd)
Publicly Listed Company (Ltd)
Self Managed Superannuation Fund
Sole Trader
Superfund
Trust
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:
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Situation at Risk
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Business Address
Address Line 1:
Address Line 2:
Town/Suburb:
Postcode:
State:
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Employees
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Annual Gross Turnover
Number of employees (ACT)
Number of employees (NSW)
Number of employees (NT)
Number of employees (QLD)
Number of employees (SA)
Number of employees (VIC)
Number of employees (WA)
Number of employees (TAS)
Number of employees (outside of Australia)
Weekly payments to subcontractors ($AUD)
Is cover required for subcontractors?
Yes
No
Import / Export
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Directly import or export raw materials, components or products?
Yes
No
List each exported product with the destination country and estimated annual turnover
What is the total value in any one shipment (exports)?
List each imported product with the country of origin and estimated annual turnover
What is the total value in any one shipment (imports)?
Vehicle Details
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Vehicle Details #1
Vehicle Year
Vehicle Make
Vehicle Model
Vehicle Variant, body type and transmission
Vehicle Registration
VIN / Chassis Number
Who owns this vehicle?
Interested Parties
Yes
No
Interested Party Type
Please select
Bank/Financial Institution
Lessor
Other
Other Interested Party Type
Interested Party Name
Vehicle Use
Please select
Private
Business
+ Vehicle Details
Activities
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Do you do any of the following high-risk activities?
24-hour transport operations
Accessing or operating airside or on airfields
Accident scene recovery
Blasting or explosives work
Demolition work
Dual / Multi crane lifts
Oil / Petrochemical / Gas extractions and/or exploration
Operating on or in close proximity to rail tracks
Operating on or over water
Operating underground at any time
Scaffolding
Two-up operations
Use vehicles with fixed cooking apparatus
If yes to any of the above, please provide details
Are your motor vehicles
Used with fixed cooking apparatus
Used for racing or testing purposes
Used for purposes of display in demonstrations, trade shows, or like events (incl. circus, carnival, parade, or film)
If yes to any of the above, please provide details
Insurance History
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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
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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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