Application Form - Commercial Facility

Quotation / Proposal Form Business Insurance

"Your Privacy"

Recently enacted privacy laws, effective 21 December 2001, require Us to make the following disclosures before collecting personal information about You after that date:

 We require personal information about You to assess Your Proposal for insurance and to administer the Policy. We may disclose Your personal information (other than sensitive information such as health information) to Your adviser (and any licensee or broker he or she represents). We may also disclose Your personal information to Our service providers (including loss adjusters, administrators, reinsurers) and to Our business partners for this purpose. By submitting Your Proposal, You consent to Us and those organisations, collecting and disclosing sensitive information about You;  if You do not provide the requested information, Your Proposal may not be accepted, We may not be able to administer Your Policy or You may breach Your Duty of Disclosure, the consequences of which are set out in the Duty of Disclosure Notice;  We may also disclose personal information about You as required or permitted by law;  in most cases, on request, We will give You access to the personal information We hold about You;  You may contact Us by telephone on 132 687, e-mail Us at [email protected] or in writing to "The Privacy Officer" at Zurich Australian Insurance Limited, P.O. Box 677, North Sydney, 2059. Please provide details of Your policy number/s where known.

(Name of Broker) : Business Insurance Quotation / Proposal Form

To (IBNA) Underwriter: Zurich Insurance Australia Limited

Date: Broker Contact: CLIENT DETAILS

Insured Name(s): ______

Insured’s ABN: ______Post Code: Address: ______

Business Description: ______

Period of Insurance: From / / To / / at 4 pm.

INSURANCE HISTORY

Have you, your spouse, your partner or in the case of a company the Directors, either alone or conjointly through partnerships or Directorships in other companies:-

(a) Ever had any insurance refused, cancelled , declined or had increased terms imposed. Yes No (b) Sustained any losses or claims during the last 5 years for those sections to be insured by this contract? Yes No If Yes to any of above, please provide details: ______

______

During the past five years- (1) been declared bankrupt? Yes No (2) been charged or convicted of a criminal offence? Yes No If Yes to any of above, please provide details: ______

______

Any other information to disclose in accordance with your Duty of Disclosure?

______

INSURANCES REQUIRED: The following insurances are required :- Fire - Gold (accidental damage cover): Yes No Fire - Silver (defined events cover): Yes No Business Interruption - annual: Yes No Business Interruption - weekly: Yes No 04e4c1f7fc51b505b27dbfe04979a1ec.doc Liability - General and Product: Yes No Burglary: Yes No Money: Yes No Glass: Yes No Special Risks: Yes No Electronic Equipment: Yes No Engineering Plant: Yes No Employee Fidelity (fraud): Yes No

PROPERTY SECTION Yes No

The following standard information is required for each location to be insured. If more than one location, complete the appendix for locations 2 and 3) Location 1 Situation: ______

Name of Interested Party: (if applicable)______

Occupation of Premises: ______

Year Built: ______Year last rewired: ______

Construction: Walls: ______Roof: ______Floor: ______Frames: ______

Adjacent Risk(s) Occupation: ______

Is this situation on town water supply? Yes No Fire Protection: Fully Sprinkled: Yes No Partially Sprinkled: Yes No Hydrants & Hose Reel: Yes No Alarms: Yes No Extinguishers: Yes No Smoke Detectors: Yes No Other Protection: Yes No ______

Hazardous Goods Storage - Provide details: ______Quantity Stored: ______Basis of cover: Gold Accidental Loss or Damage: Yes No Is this Mortgage Protection Cover only? Yes No Silver Fire and Defined Events: Yes No SUMS INSURED: FIRE INSURANCE Location 1. Location 2. Location 3. Building. $ $ $ Contents, Plant & Machinery. $ $ $ Stock, Work in Progress. $ $ $ Removal of Debris. $ $ $ Customers Goods. $ $ $ Specify other itmes of property $ $ $ Specify other items of property $ $ $ TOTAL $ $ $

OPTIONAL EXTENSIONS: Gold: 1. Flood: Yes No

04e4c1f7fc51b505b27dbfe04979a1ec.doc If Yes, details of flood exposure required before acceptance of flood cover: ______

______

Silver: 2. Transit: Yes No (Cover is extended under this section to include fire/ collision/ overturing. Cover is not available for Professional Carriers) Number of Goods Carrying Vehicles: ______Sum Insured per Vehicle: $ ______

3. Flood: Yes No

If Yes, details of flood exposure required before acceptance of flood cover: ______

______

4. Accidental Damage: Yes No If Yes, Limit required; $ ______EXCESS - Gold and Silver Earthquake - the lesser of $10,000 or 1% of the Sum Insured / Declared Value at the Premises where the loss occurs. Malicious damage (if standard policy excess increased) $ ______Flood (if available and included) $ ______Transit (if included) $ ______All other events $ ______

BUSINESS INTERRUPTION SECTION - ANNUAL Yes No

INCOME Yes No $ ______RENTAL Yes No $ ______Payroll - Do you require Payroll to be insured Yes No $ ______(100% of Payroll is included under the cover unless indicated below ) Percentage of Annual Payroll to be insured: 0% 10% 25% 50% 75%

Sum Insured Indemnity period Months

Loss of Income / Rental $ ______Payroll $ ______

Optional Extensions: Other Premises* Yes No (see note below) Specified Customers $ ______Specified Suppliers $ ______Additional Increase in Cost of Working Accounts Receivable $ ______Additional Claims Preparation Costs (cover for up to $20,000 is included under the $ ______General Conditions and Limitations of Cover Section of the policy) Cost of Good Will $ ______04e4c1f7fc51b505b27dbfe04979a1ec.doc TOTAL $

*( NOTE: Cover is included for unspecified Customers and Suppliers up to 20% of the Sum Insured)

BUSINESS INTERRUPTION SECTION -WEEKLY Yes No

Sum Insured Indemnity period Weeks

Weekly Income $ ______

Optional Extensions: Increase in Cost of Working $ ______Other Premises* (see note below) Specified Customers $ ______Specified Suppliers $ ______

TOTAL $

*( NOTE: Cover is included for unspecified Customers and Suppliers up to 20% of the Sum Insured)

PUBLIC / PRODUCTS LIABILITY SECTION Yes No

Estimated annual turnover: $ ______Number of staff: ______Estimated annual wages: $ ______

Estimated value of annual contracts let to sub-contractors $ ______

Any welding off site?: Yes No Do you require Property Owners liability? Yes No If Yes, what is the square metres of the premises: ______M2.

Number of years experience in this business?: ______

Please provide full details of your businesses activities: ______

______

SUMS INSURED LIMIT OF LIABILITY

General Liability $ ______Product Liability $ ______Treatment Risk $ ______Property in Physical & Legal Control (in excess of $100,000) $ TOTAL $

EXCESS – (if standard policy excess increase) All claims $ ______

04e4c1f7fc51b505b27dbfe04979a1ec.doc Extensions included as part of the standard cover: Boiler & Pressure Vessels; Car Parks; Tenants Lease Liability; Cross Liability; Principals Indemnity; Tenants Liability for Fire; Flood, Explosion and Impact.

SUB-CONTRACTORS The cover provided to you for the liability of sub-contractors is limited to your liability as Principal. If you sub-contract any part of your work to others, you may incur additional liability for the work performed by the sub-contractor and/or their employees. If you require additional insurance cover for sub-contractors please discuss your requirements with your IBNA broker.

PRODUCTS LIABILITY SECTION

Do you Export to the United States or Canada? Yes No If Yes, provide details of Products Exported or Imported:

Product Description Destination / Source Annual Turnover

BURGLARY SECTION Yes No

PROPERTY INSURED SUM INSURED All Contents (including. Stock) $ Stock $ Furniture/Fixtures/Fittings $ Tools/Computers $ Cigarettes/Liquor $ TOTAL $ (Note: If All Contents, including Stock is insured as a total amount, higher rates will apply)

Do you wish to insure specified items ? If so please provide details: ______

______

Do you wish to have a seasonal increase in your sums insured? Yes No

Please nominate the three calendar months when you want this to apply : ______

OPTIONAL EXTENSIONS: Additional Damage to Premises Yes No Limit required $ ______Theft without forcible entry Yes No Limit required $ ______

EXCESS – (if standard policy excess increased) All claims $ ______

SECURITY DETAILS

04e4c1f7fc51b505b27dbfe04979a1ec.doc The following information is required for each location to be insured. If more than one location, complete the appendix for locations 2 and 3.

Location 1 Deadlocks on all External Doors Yes No Key-locks on all Windows Yes No Bars/Grills on Windows Yes No Local Alarm: Yes No Back to Base Alarm Yes No Other (please detail): ______

MONEY SECTION Yes No

Option A - Blanket Cover (includes all of the specified covers) Yes No Option B - Specified Cover Yes No

PROPERTY INSURED SUM INSURED

Option A – or ($1,000 limit applies outside business hours) $

Option B - Money in Transit & Wages 1. In transit outside of the Premises; $ In a bank night safe; $ Money on the Premises withdrawn for payment of wages or salaries $ 2. On the Premises (not in locked safe or strongroom) $ 3. On the Premises (in locked safe or strongroom) $ 4. In Personal Custody $ TOTAL $

OPTIONAL EXTENSIONS: Additional Damage to Safes and Strongrooms: Yes No Limit required $ ______($5,000 limit is included under the standard cover) Money on the Premises during non Business Hours: Yes No Limit required $ ______($1,000 limit is included under the standard cover)

Do you wish to insure specified items ? If so please provide details: ______

______

Do you wish to have a seasonal increase in your sums insured? Yes No

Please nominate the three calendar months when you want this to apply : ______

04e4c1f7fc51b505b27dbfe04979a1ec.doc GLASS SECTION Yes No

PROPERTY INSURED REPLACEMENT Frontage of building Single Double Multiple Internal Fixed Glass Yes No External Fixed Glass Yes No

OPTIONAL EXTENSIONS: Advertising (or Identification) Signs: Yes No Limit required $ ______Increased Additional Benefits: Yes No Limit required $ ______(Provide Details) ______

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ADDITIONAL BENEFITS (a) Temporary repairs, install shuttering and employ watchman or guards; (b) Repair or replace frames, sign-writing, alarm tapes, coatings; fittings or stock that are damaged by glass breakage; (c) Remove and refit fixtures and tiles to allow repair or replacement of broken glass; (d) Arrange for after hours services, express delivery and labour at overtime rates. Cover is limited to $5,000 during the period of insurance.

Extra Costs of Replacement to comply with current building regulations that relate to glass that is broken Repair or replace Stock that is damaged by broken glass. Cover is limited to $5,000 during the period of insurance.

BUSINESS SPECIAL RISKS SECTION Yes No

Option A – Unspecified Tools of Trade (Limit $1,000 any one item) Yes No $ Option B – Specified Items Yes No

(Excludes the following items unless specified in the Schedule: mobile plant, motor vehicles, watercraft, video equipment; stock; mobile telephones and radios, sporting equipment, aerial devices; and computers or their accessories).

SPECIFIED ITEMS SUM INSURED 1. $ 2. $ 3. $ 4. $ 5. $ 6. $ 7. $ TOTAL $

OPTIONAL LIMITATION: Restricted Cover Yes No 04e4c1f7fc51b505b27dbfe04979a1ec.doc Loss or Damage caused by: (a) fire, storm, water, explosion, impact by vehicles; (b) earthquake, aircraft, malicious damage; (c) collision or overturning of a vehicle; and (d) theft following visible, forcible and violent entry to locked vehicles or locked Premises.

Fire Damage Excluded Yes No

EXCESS – All claims $ ______

EMPLOYEE FRAUD (FIDELITY) SECTION Yes No

Option A - Blanket Cover (includes all employees) Yes No Option B - Specified Employees Yes No

Option A: Number of Employees Limit per Employee $ ______

Option B:

Name Position / Title Sum Insured $ $ $ $ $ $ $

MACHINERY BREAKDOWN SECTION Yes No

Number of Units to be insured: ______

PROPERTY INSURED SUM INSURED Electrical, Electronic and Mechanical Plant and Machinery. $ $ $ $ $ $ TOTAL $ 04e4c1f7fc51b505b27dbfe04979a1ec.doc OPTIONAL EXTENSIONS:

Deterioration of Refrigerated Stock: Yes No Limit required $ ______

Increased Cost of Working Yes No Limit required $ ______

EXCESS – (if standard policy excess increased All claims $ ______

ELECTRONIC EQUIPMENT SECTION Yes No

Part A - Material Loss or Damage Yes No Part B - Breakdown Yes No

PROPERTY INSURED SUM INSURED Computer and Electronic Equipment. Desk-tops $ Lap-tops – (to be specified or attach list) $ Office Equipment (eg. Faxes, photo copiers, printers, scanners) $ TOTAL $

OPTIONAL EXTENSIONS: Part A Damage to Premises During a Theft: Yes No Limit required $ Part A and B Costs of Restoring Data: Yes No Limit required $ Increased Cost of Working: Yes No Limit required $ Temporary Removal: Yes No Limit required $

Schedule of lap-top computers Manufacturer Model Serial Number Value $ $ $ $ $ $

04e4c1f7fc51b505b27dbfe04979a1ec.doc IMPORTANT MATTERS REFERRED TO IN THE INSURANCE CONTRACTS ACT 1984

YOUR DUTY OF DISCLOSURE Before you enter into a contract of general insurance with us, you have a duty, under the Insurance Contracts Act 1984, to disclose to the insurer every matter that you know, or could reasonably be expected to know, is relevant to the insurer (s) decision whether to accept the risk of insurance and, if so, on what terms.

You have the same duty to disclose those matters to us before you renew, extend, vary or reinstate your contract of general insurance.

Your duty does not however, require disclosure of matters  that diminishes the risk to be undertaken by us;  that are of common knowledge;  that we know or, in the ordinary course of your business ought to know;  as to which compliance with your duty is waived by us.

NON-DISCLOSURE

If you fail to comply with your duty of disclosure, we may be entitled to reduce our liability under the Contract in respect of a claim or may cancel this Contract. If your non-disclosure is fraudulent, we may also have the option of avoiding the Contract from. its beginning.

UNDERINSURANCE (applicable to GOLD and SILVER FIRE INSURANCE) Underinsuring your property or your Business Interruption cover could be false economy, for example, under the Fire Sections the Sum Insured must be at least 80% of the full cost of replacing the building, and include an allowance for additional fees and costs which would be payable. If it is not, the Insurers Liability will be limited to the proportion that the Sum Insured bears to 80% of the actual cost of replacing the building including an allowance for additional fees and costs.

SUM / 80% of full value at the X Amount of = Amount payable by the Insurer INSURED time of inception of the Loss (not exceeding the Sum Insured) insurance

REASONABLE PRECAUTIONS AND FRAUDULENT ACTS You must take all reasonable cautions for the maintenance and safety of the Insured Property. We will not be liable for any loss, damage, injury or liability arising from a deliberate act committed by you or on your behalf.

DECLARATION I / We in effecting insurance in accordance with the information furnished in his application declare and warrant: (a) The statements in this Proposal Form are true. (b) I / We have disclosed all matters which to my / our knowledge you should be aware of. (c) No Insurance Company has ever cancelled, declined or refused to renew or imposed special terms or conditions on any policy held my me / us other than those circumstances disclosed therein. (d) That I / We have read and agree to accept the terms, exclusions, conditions and limitations of the IBNA Business Insurance Policy. (e) That any answer not in my / own handwriting have been checked by me / us and are correct. (f) The signatories appearing below are authorised to sign on behalf of all proposers.

DATE: ……………/……………../………………

SIGNATURE: ……………………………………………………………………

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WORKERS’ COMPENSATION Although IBNA Business Insurance does not include a Workers’ Compensation component, you are required by law to have Workers’ Compensation insurance if you employ anyone.

SO DON’T FORGET YOUR WORKERS’ COMPENSATION! You can’t avoid Workers’ Compensation, so why not do the next best thing and resolve it now? Simply ask us to take care of your Workers’ Compensation insurance to ensure quality coverage for ALL your business insurance needs.

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