Surety General Insurance Brokers

Office Contents, Laptop, Public Liability

This application enables you to apply for the above covers.

You can choose one, or any combination of these covers, depending on your needs or requirements.

The application process is extremely straightforward, complete the proposal form below and click submit. Once we receive your application form we will process this and contact you with your premium details.

If you have any questions or need assistance in the completion of this application please contact us.

Coverage Required

Please select at least one type of coverage from the below selection.

Note – if you wish to insure more than one section below, you only need to complete one proposal form.

Office Contents:

Laptop Computers - (Coverage for Laptops or other portable equipment removed from your office?)

Enter the amount of cover required:

Public Liability - select the cover that you require:

Period of Cover

to 28/03/2011 (Note:Cover cannot be backdated)
(28/03/2011 is a common renewal date)

If you require a different commencement date please enter it here:

Insured Detail

Insured Name:

Enter your MFAA member number OR tick 'To be confirmed'

MFAA number: To be confirmed:

Contact Details

First Name:

Last Name:

eMail:

Contact phone:

Address of Insured's Office

Address: Suburb:

Postcode: State:

Please include any additional insured occupied office to be covered (if you operate more than 1)by including the addresses in the following text box:

Addresses of additional offices:

Claims Declaration

Are there now pending, or have there been any suits, claims or proceedings against you?

Yes No

If you have answered "yes" please provide details below. Eligibility to participate in this policy will be subject to the insurer's acceptance. S&G will contact you to discuss your application further.

Declaration

Are you aware of any other fact or circumstance that may give rise to a claim under the contract of insurance if a policy is issued or which may be relevant to the insurer's decision whether to accept the risk of the insurance and if so, on what terms?