(08) 6147 3200
ultra@uis.com.au
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Contacts
Situation at Risk
Insurance History
Additional Information
Contacts
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Name
Email
Phone number/mobile
Date of birth
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
Describe business structure
ABN
Company or Insured name
Trading as
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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Next
Is the business address the same as the mailing address?
Yes
No
Business address
(Cannot be a PO Box)
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
Insurance History
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Next
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, dishonestly, arson, theft, fraud, or violence against any person or property, including association with Outlaw Motorcycle Gangs or Organised Crime Gangs?
Yes
No
If yes to any of the above questions, please provide details. Alternatively, call us on (08) 6147 3200.
Claims History
In the last five years has the owner or business suffered any loss or claims made against you that has not already been declared?
Yes
No
List any claims from the last 5 years
Insurer
Claim date
Type of claim
Amount paid
Finalized
Description
Please select
Malicious Damage
Water Discharge/Burst Pipe
Glass External/Internal
Impact/Vehicle
Theft/Burglary
Liability – Property
Liability – Personal Injury
Electrical/Fusion/Pumps
Other
Storm Damage – Building/Contents
Fire
Accidental Damage
Storm Other
Malicious Damage
Hail Damage
Storm Damage - Fence
$
Please select
Finalized
Not Finalized
Additional Information
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Submit
Please provide any additional information relevant to your risk, or additional covers you may require
Policy effective date
Policy expiry date
Would you like to pay monthly?
Yes
No
Who is your current insurer?
What is your current premium?
$
What is your current excess?
$
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