Insurance House Surety

Stratapractice

Stratapractice - Other cover

Office Contents Laptop Public Liability Office, Laptop, Public Liability Application Form

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:

Do you require Plate Glass including Internal Glass: Yes No

Contents Cover automatically includes Removal of Debris $5,000 and Rewriting of Records $5,000.

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

Enter the total amount of cover required:

Details of Items to be insured:

	Item Description	Sum Insured

Please advise us of any additional items:

Public Liability - select the cover that you require:

Does the Insured require this policy to cover contractors or sub-contractors? Yes No

Period of Cover

/ / 2009 for 12 months

Insured Detail

Insured Name:

Enter your Peak Body number OR tick 'To be confirmed'

Peak Body number: To be confirmed:

Contact Details

First Name:

Last Name:

eMail:

Contact phone:

Address of Insured's Office

Address: Suburb:

Postcode: State:

Construction risk Details:

Do the premises have a fire sprinkler system:	Yes No
Is there more than 15% Sandwich Foam Construction:	Yes No
Do the premises comply with Fire & Council regulations:	Yes No
Are the premises connected to town water and in the area of a permanently manned Fire Station:	Yes No

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:

Please confirm the number of employees including Principals

Claims Declaration

Has the Insured, or this business had 2 or more liability claims within the last 3 years or are You aware of circumstances that may give rise to a claim. Yes No

Have you had any General Property & or Office Contents claims in the last 3 years? Yes No

If you have answered "yes" to the above claims declarations please provide details below. Eligibility to participate in this policy will be subject to the insurer's acceptance. Insurance House Surety 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?

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. Insurance House Surety will contact you to discuss your application further.

Confirm Cover & Submit

Insurance House Surety will contact you shortly to confirm premiums for your application. If you have any queries, please contact Insurance House Surety on 02 8913 9100.