Business Package 1Broker & Insured Details2History3Public and Products Liability4Situation 15Situation 26Situation 37Situation 4 Completion of this Form Please answer all questions. Please tick appropriate boxes and provide details as requested. If there is not enough space provided to answer a question please complete Your answer on a separate page and attach it to the Proposal. Acceptance of Proposal Cover for this insurance will not commence until agreed and accepted by Coast in writing. Coast reserves the right to decline any Proposal and to verify any information provided. Internal Dispute Resolution Process (IDR) What to do if you have a complaint Complaints may be referred by either email, telephone or mail: E: info@coastins.com.au T: +61 (0)8 6374 7000 M: Service Feedback PO Box 120, Mount Hawthorn WA 6915 Defined Terms Some words used in this Proposal Form (‘Proposal’) have a special meaning as defined in the Policy wording and such other documents that make up the Policy which contain definitionsIndustrial Special Risk (ISR) If the property is an ISR, please email your slip to: info@coastins.com.auBroker DetailsBroker's Name* Contact Phone Number* Brokerage* Email* Client DetailsInsured's Name*Business Description*Please describe your businessInterested Party ABN Website Policy Inception Date* DD slash MM slash YYYY Who is the current Insurer? When does the current policy fall due? DD slash MM slash YYYY How long has the insured operated this business?*Please selectNew businessLess than 5 yearsMore than 5 yearsIs there anything else you would like to tell us?Please provide detailed information in regards to insured's experience (if less than 5 years)Has the insured ever had an insurance policy declined, cancelled or special conditions imposed?* No Yes (please provide details) Insurance policy declined answer*Has the insured ever been declared bankrupt* No Yes (please provide details) Bankrupt answer*Has the insured ever been convicted of any criminal offence (other than minor traffic convictions)?* No Yes (please provide details) Criminal offence answer*Has the insured suffered any losses in the last 5 years?* No Yes (please provide date of loss / details of incident and settlement amount) Insured suffered any losses answer*Claims Status* Ongoing Closed Public and Products LiabilityDo you require cover for Public & Products liability?* Yes No Is this cover for Property Owner's Liability only?* Yes No What is the gross annual rental income?*What limit of liability do you require?* $20,000,000 $10,000,000 What excess do you require?* $500 $1,000 $2,500 $5,000 10,000 TurnoverTurnover*What is the estimated turnover/gross income for the next 12 months?Please list all activities this business carries out and the approximate turnover derived from each.*Business descriptionType of Work% of Turnover Please provide the approximate percentage of turnover derived from each State, Territory or Overseas.*State% of Turnover Overseas - (if overseas, please list countries)Country% of Turnover PersonnelStaff* Number of StaffEstimated Payroll*Do you engage subcontractors?* Yes No If yes, what activities do you contract to them?*What are your estimated payments to contractors?*Labour Hire - Do you engage labour hire personnel?* Yes No What are your estimated payments to labour hire?*Imported GoodsDo you, or do you intend to import goods? Yes No If yes, please specify the items and the country imported fromItemsCountry (imported from)Value of Import ($) Do you have quality control procedures in place?* Yes No If yes, please provide details*Are your products subject to any Australian or International standard?* Yes No If yes, please provide details*Exported GoodsDo you, or do you intend to export goods?* Yes No If yes, please specify the items and the country exported toItemsCountry (exported to)Value of Export ($) Do you have quality control procedures in place?* Yes No If yes, please provide details*Are your products subject to any Australian or International standard?* Yes No If yes, please provide details*Hazardous Activities and SubstancesDo You, or do You intend to use, store or handle hazardous substances?* Yes No If yes, please specify the substances*Do You, or do You intend to, discharge waste or hazardous material into the atmosphere, sewer or elsewhere?* Yes No If yes, please provide details*Waste MaterialPlease provide detailsMethod of StoragePlease provide detailsSafety ProceduresPlease provide detailsActivitiesDo You, or do You intend to carry out any of the following?* Use of explosives Bridge construction/maintenance Demolition activities Work on offshore platforms Utilities, gas production, petrochemical plants, power stations Height work Construction or maintenance work involving chemical works Work of or in the defence force Mining or in the mining industry Work on aircraft or their components Rail or trains None of the above Please provide details* Situation 1How many situations are there?*Please select1234Situation 1 Address* Street Number (include unit number, if applicable) Street Name Suburb State Postcode Occupancy Type*Please selectOwner OccupiedProperty OwnerTenantUnoccupiedUnoccupied Property If the property is unoccupied please complete the unoccupied form Business Activities at this Location (or Tenant's Activities)* BuildingNumber of Buildings*Please select12345 or moreYear Built* Year (Re)wired Number of Stories*Please select1234 or moreRoof Shape*Please selectFlatPeakedNot InsuredOther (please provide details)Roof shape answer* Is there EPS/PIR/PUR Panels in the structure?*Please selectNoYesPlease provide the percentage of EPS/PIR/PUR in the structure Floors Construction*Please selectConcreteWoodIron/SteelOther (please provide details)Floors Construction - Other answer Walls Construction*Please selectConcreteIron/Steel/AluminiumBrick/MasonryWoodGlassEPS/Other (please provide details)Walls Construction - other answer Roof Construction*Please selectConcreteIron/Steel/AluminiumTiles/SlateMasonryAsbestosWoodEPS/Other (please provide details)Roof Construction - other answer Fire Protection - What fire protection is present and in working order?* No fire protection Sprinklers Smoke Detectors - monitored Smoke Detectors - not monitored Hose Reels - partial floor area Hose Reels - total floor area Fire Extinguishers Heat Detectors Fire Blankets Other Please provide more details Security - What security is provided?* No security Alarm - local alarm Alarm - monitored / back to base Deadlocks on doors Bars on windows Roller shutters CCTV Patrols Electronic key pad / swipe card access Security fencing External lighting Other Please provide more details Location - Which of the following best describes where the buildings are located?*Please selectMain or Suburban StreetWithin an Industrial ComplexOutside Metropolitan, regional or town boundariesWholly within a shopping centre (no external openings to outside centre)Within a shopping centre (with external openings)Within an Office Block (including ground or 1st floor)Within an Office Block (2nd floor or above)OtherPlease provide details Is the premises connected to town water* Yes No Fire Brigade - Distance to nearest Fire Brigade*Please selectLess than 5 km5-20 kmMore than 20 kmType of Fire Brigade*Please selectProfessional Manned 24 hoursProfessional Manned part timeOwn on site staff fire brigade Manned 24 hoursRural or country volunteer brigadeFlammable Goods - Are flammable goods stored on the premises?* No Yes What quantity?* In approved cabinets/bunded storage facilities?* Yes No Cover RequiredWhat cover do you require for this Situation?* Business Property Business Interruption Theft Money Glass Machinery Breakdown and Electronic Equipment General Property Tax Audit Business PropertyDescription of Property Sum Insured*Stock Stock Sum InsuredAll Contents other than Stock All Contents other than Stock Amount Free-text Property Line 1 Free-text Property Line 1 answer Free-text Property Line 2 Free-text Property Line 2 Answer Free-text Property Line 3 Free-text Property Line 3 Answer Total Sum InsuredOther Covers Other AmountRemoval of Debris Other Amount DebrisRewriting of Records Other Amount Rewriting of RecordsFlood No Yes Flood amount answerBusiness InterruptionSub-limit*Please selectInsurable Gross ProfitAnnual RevenueLoss of Rent ReceivableBusiness Interruption Amount*Other Covers Other AmountB.I Claims Preparation Costs B.I Claims Preparation Costs amountIndemnity Period* PayrollIf not insured 100% in Gross ProfitLoss of PayrollPlease details for loss of payrollDo you wish to provide further information?TheftDescription of Cover Sum InsuredLiquor Products Liquor Products Sum InsuredStock, other than tobacco or liquor Stock, other than tobacco or liquor Sum InsuredMachinery & Plant Machinery & Plant Sum insuredTheft (limited) without forcible and violent entry Theft (limited) without forcible and violent entry sum insured1st blank choice - Theft 1st blank choice - Theft sum insured2nd blank choice - Theft 2nd blank choice - Theft sum insuredOther Covers Other AmountDamage to rented premises Rented Premises Other AmountSeasonal increase period/s Seasonal Increase periods AmountDirectors & employees tools of trade and personal effects Directors & employees tools of trade - amountEmployee dishonesty Employee dishonesty - amountMoneyDescription of Cover Sum InsuredOn premises – Business Hours On premises – Business Hours Sum InsuredOn premises – Outside Business Hours On premises – Outside Business Hours Sum InsuredIn a locked safe Locked safe Sum InsuredIn Private Residence In Private Residence Sum InsuredBlank Money line 1 Blank line 1 answerBlank Money line 2 Blank line 2 answerGlassWhat glass cover do you require?*Please selectInternal glassExternal glassBoth internal & external glassDo you wish to add any specified glass items?* Yes No Specified Glass Items AnswerPlease specifyTax AuditInsured Event*Please select$10,000Other Amount (please specify)Tax Audit - Other amount answerTurnover*What is the estimated turnover / gross income for the next 12 months?Machinery Breakdown and Electronic EquipmentSpecified Machinery Sum InsuredSpecified Machinery - line 2 Sum Insured - line 2Specified Machinery - line 3 Sum Insured - line 3Specified Machinery - line 4 Sum Insured - line 4Specified Machinery - line 5 Sum Insured - line 5Specified Machinery - line 6 Sum Insured - line 6Specified Electronic Equipment Sum InsuredSpecified Electronic Equipment - line 2 Sum Insured Electronic - line 2Specified Electronic Equipment - line 3 Sum Insured Electronic - line 3Specified Electronic Equipment - line 4 Sum Insured Electronic - line 4Specified Electronic Equipment - line 5 Sum Insured Electronic - line 5Specified Electronic Equipment - line 6 Sum Insured Electronic - line 6Optional Extras - Do you require cover for Deterioration of stock? Yes No General PropertySpecified Property Sum InsuredSpecified Property - line 2 Sum Insured - line 2Specified Property - line 3 Sum Insured - line 3Specified Property - line 4 Sum Insured - line 4Specified Property - line 5 Sum Insured - line 5Specified Property - line 6 Sum Insured - line 6 Situation 2Situation 2 Address* Street Number (include unit number, if applicable) Street Name Suburb State Postcode Occupancy Type*Please selectOwner OccupiedProperty OwnerTenantBusiness Activities at this Location (or Tenant's Activities)* BuildingNumber of Buildings*Please select12345 or moreYear Built* Year (Re)wired Number of Stories*Please select1234 or moreRoof Shape*Please selectFlatPeakedNot InsuredOther (please provide details)Roof shape answer* Is there EPS/PIR/PUR Panels in the structure?*Please selectNoYesPlease provide the percentage of EPS/PIR/PUR in the structure Floors Construction*Please selectConcreteWoodIron/SteelOther (please provide details)Floors Construction 2 - Other answer Walls Construction*Please selectConcreteIron/Steel/AluminiumBrick/MasonryWoodGlassEPS/Other (please provide details)Walls Construction - other answer Roof Construction*Please selectConcreteIron/Steel/AluminiumTiles/SlateMasonryAsbestosWoodEPS/Other (please provide details)Roof Construction - other answer Fire Protection - What fire protection is present and in working order?* No fire protection Sprinklers Smoke Detectors - monitored Smoke Detectors - not monitored Hose Reels - partial floor area Hose Reels - total floor area Fire Extinguishers Heat Detectors Fire Blankets Other Please provide more details Security - What security is provided?* No security Alarm - local alarm Alarm - monitored / back to base Deadlocks on doors Bars on windows Roller shutters CCTV Patrols Electronic key pad / swipe card access Security fencing External lighting Other Please provide more details Location - Which of the following best describes where the buildings are located?*Please selectMain or Suburban StreetWithin an Industrial ComplexOutside Metropolitan, regional or town boundariesWholly within a shopping centre (no external openings to outside centre)Within a shopping centre (with external openings)Within an Office Block (including ground or 1st floor)Within an Office Block (2nd floor or above)OtherPlease provide details Is the premises connect to town water* Yes No Fire Brigade - Distance to nearest Fire Brigade*Please selectLess than 5 km5-20 kmMore than 20 kmType of Fire Brigade*Please selectProfessional Manned 24 hoursProfessional Manned part timeOwn on site staff fire brigade Manned 24 hoursRural or country volunteer brigadeFlammable Goods - Are flammable goods stored on the premises?* No Yes What quantity?* In approved cabinets/bunded storage facilities?* Yes No Cover RequiredWhat cover do you require for this Situation?* Business Property Business Interruption Theft Money Glass Machinery Breakdown and Electronic Equipment Business PropertyDescription of Property Sum Insured*Stock Stock Sum InsuredAll Contents other than Stock All Contents other than Stock AmountFree-text Property Line 1 Free-text Property Line 1 answerFree-text Property Line 2 Free-text Property Line 2 AnswerFree-text Property Line 3 Free-text Property Line 3 AnswerTotal Sum InsuredOther Covers Other AmountRemoval of Debris Other Amount DebrisRewriting of Records Other Amount Rewriting of RecordsFlood No Yes Flood amount answerBusiness InterruptionSub-limit*Please selectInsurable Gross ProfitAnnual RevenueLoss of Rent ReceivableBusiness Interruption Amount*Other Covers Other AmountB.I Claims Preparation Costs B.I Claims Preparation Costs amountIndemnity Period* PayrollIf not insured 100% in Gross ProfitLoss of PayrollPlease details for loss of payrollDo you wish to provide further information?TheftDescription of Cover Sum InsuredLiquor Products Liquor Products Sum InsuredStock, other than tobacco or liquor Stock, other than tobacco or liquor Sum InsuredMachinery & Plant Machinery & Plant Sum insuredTheft (limited) without forcible and violent entry Theft (limited) without forcible and violent entry sum insured1st blank choice - Theft 1st blank choice - Theft sum insured2nd blank choice - Theft 2nd blank choice - Theft sum insuredOther Covers Other AmountDamage to rented premises Rented Premises Other AmountSeasonal increase period/s Seasonal Increase periods AmountDirectors & employees tools of trade and personal effects Directors & employees tools of trade - amountEmployee dishonesty Employee dishonesty - amountMoneyDescription of Cover Sum InsuredOn premises – Business Hours On premises – Business Hours Sum InsuredOn premises – Outside Business Hours On premises – Outside Business Hours Sum InsuredIn a locked safe Locked safe Sum InsuredIn Private Residence In Private Residence Sum InsuredBlank Money line 1 Blank line 1 answerBlank Money line 2 Blank line 2 answerGlassWhat glass cover do you require?*Please selectInternal glassExternal glassBoth internal & external glassDo you wish to add any specified glass items?* Yes No Specified Glass Items AnswerPlease specifyMachinery Breakdown and Electronic EquipmentSpecified Machinery Sum InsuredSpecified Machinery - line 2 Sum Insured - line 2Specified Machinery - line 3 Sum Insured - line 3Specified Machinery - line 4 Sum Insured - line 4Specified Machinery - line 5 Sum Insured - line 5Specified Machinery - line 6 Sum Insured - line 6Specified Electronic Equipment Sum InsuredSpecified Electronic Equipment - line 2 Sum Insured Electronic - line 2Specified Electronic Equipment - line 3 Sum Insured Electronic - line 3Specified Electronic Equipment - line 4 Sum Insured Electronic - line 4Specified Electronic Equipment - line 5 Sum Insured Electronic - line 5Specified Electronic Equipment - line 6 Sum Insured Electronic - line 6Optional Extras - Do you require cover for Deterioration of stock? Yes No Situation 3Situation 3 Address* Street Number (include unit number, if applicable) Street Name Suburb State Postcode Occupancy Type*Please selectOwner OccupiedProperty OwnerTenantBusiness Activities at this Location (or Tenant's Activities)* BuildingNumber of Buildings*Please select12345 or moreYear Built* Year (Re)wired Number of Stories*Please select1234 or moreRoof Shape*Please selectFlatPeakedNot InsuredOther (please provide details)Roof shape answer* Is there EPS/PIR/PUR Panels in the structure?*Please selectNoYesPlease provide the percentage of EPS/PIR/PUR in the structure Floors Construction*Please selectConcreteWoodIron/SteelOther (please provide details)Floors Construction 3 - Other answer Walls Construction*Please selectConcreteIron/Steel/AluminiumBrick/MasonryWoodGlassEPS/Other (please provide details)Walls Construction - other answer Roof Construction*Please selectConcreteIron/Steel/AluminiumTiles/SlateMasonryAsbestosWoodEPS/Other (please provide details)Roof Construction - other answer Fire Protection - What fire protection is present and in working order?* No fire protection Sprinklers Smoke Detectors - monitored Smoke Detectors - not monitored Hose Reels - partial floor area Hose Reels - total floor area Fire Extinguishers Heat Detectors Fire Blankets Other Please provide more details Security - What security is provided?* No security Alarm - local alarm Alarm - monitored / back to base Deadlocks on doors Bars on windows Roller shutters CCTV Patrols Electronic key pad / swipe card access Security fencing External lighting Other Please provide more details Location - Which of the following best describes where the buildings are located?*Please selectMain or Suburban StreetWithin an Industrial ComplexOutside Metropolitan, regional or town boundariesWholly within a shopping centre (no external openings to outside centre)Within a shopping centre (with external openings)Within an Office Block (including ground or 1st floor)Within an Office Block (2nd floor or above)OtherPlease provide details Is the premises connect to town water* Yes No Fire Brigade - Distance to nearest Fire Brigade*Please selectLess than 5 km5-20 kmMore than 20 kmType of Fire Brigade*Please selectProfessional Manned 24 hoursProfessional Manned part timeOwn on site staff fire brigade Manned 24 hoursRural or country volunteer brigadeFlammable Goods - Are flammable goods stored on the premises?* No Yes What quantity?* In approved cabinets/bunded storage facilities* Yes No Cover RequiredWhat cover do you require for this Situation?* Business Property Business Interruption Theft Money Glass Machinery Breakdown and Electronic Equipment Business PropertyDescription of Property Sum Insured*Stock Stock Sum InsuredAll Contents other than Stock All Contents other than Stock AmountFree-text Property Line 1 Free-text Property Line 1 answerFree-text Property Line 2 Free-text Property Line 2 AnswerFree-text Property Line 3 Free-text Property Line 3 AnswerTotal Sum InsuredOther Covers Other AmountRemoval of Debris Other Amount DebrisRewriting of Records Other Amount Rewriting of RecordsFlood No Yes Flood amount answerBusiness InterruptionSub-limit*Please selectInsurable Gross ProfitAnnual RevenueLoss of Rent ReceivableBusiness Interruption Amount*Other Covers Other AmountB.I Claims Preparation Costs B.I Claims Preparation Costs amountIndemnity Period* PayrollIf not insured 100% in Gross ProfitLoss of PayrollPlease details for loss of payrollDo you wish to provide further information?TheftDescription of Cover Sum InsuredLiquor Products Liquor Products Sum InsuredStock, other than tobacco or liquor Stock, other than tobacco or liquor Sum InsuredMachinery & Plant Machinery & Plant Sum insuredTheft (limited) without forcible and violent entry Theft (limited) without forcible and violent entry sum insured1st blank choice - Theft 1st blank choice - Theft sum insured2nd blank choice - Theft 2nd blank choice - Theft sum insuredOther Covers Other AmountDamage to rented premises Rented Premises Other AmountSeasonal increase period/s Seasonal Increase periods AmountDirectors & employees tools of trade and personal effects Directors & employees tools of trade - amountEmployee dishonesty Employee dishonesty - amountMoneyDescription of Cover Sum InsuredOn premises – Business Hours On premises – Business Hours Sum InsuredOn premises – Outside Business Hours On premises – Outside Business Hours Sum InsuredIn a locked safe Locked safe Sum InsuredIn Private Residence In Private Residence Sum InsuredBlank Money line 1 Blank line 1 answerBlank Money line 2 Blank line 2 answerGlassWhat glass cover do you require?*Please selectInternal glassExternal glassBoth internal & external glassDo you wish to add any specified glass items?* Yes No Specified Glass Items AnswerPlease specifyMachinery Breakdown and Electronic EquipmentSpecified Machinery Sum InsuredSpecified Machinery - line 2 Sum Insured - line 2Specified Machinery - line 3 Sum Insured - line 3Specified Machinery - line 4 Sum Insured - line 4Specified Machinery - line 5 Sum Insured - line 5Specified Machinery - line 6 Sum Insured - line 6Specified Electronic Equipment Sum InsuredSpecified Electronic Equipment - line 2 Sum Insured Electronic - line 2Specified Electronic Equipment - line 3 Sum Insured Electronic - line 3Specified Electronic Equipment - line 4 Sum Insured Electronic - line 4Specified Electronic Equipment - line 5 Sum Insured Electronic - line 5Specified Electronic Equipment - line 6 Sum Insured Electronic - line 6Optional Extras - Do you require cover for Deterioration of stock? Yes No Situation 4Situation 4 Address* Street Number (include unit number, if applicable) Street Name Suburb State Postcode Occupancy Type*Please selectOwner OccupiedProperty OwnerTenantBusiness Activities at this Location (or Tenant's Activities)* BuildingNumber of Buildings*Please select12345 or moreYear Built* Year (Re)wired Number of Stories*Please select1234 or moreRoof Shape*Please selectFlatPeakedNot InsuredOther (please provide details)Roof shape answer* Is there EPS/PIR/PUR Panels in the structure?*Please selectNoYesPlease provide the percentage of EPS/PIR/PUR in the structure Floors Construction*Please selectConcreteWoodIron/SteelOther (please provide details)Floors Construction 3 - Other answer Walls Construction*Please selectConcreteIron/Steel/AluminiumBrick/MasonryWoodGlassEPS/Other (please provide details)Walls Construction - other answer Roof Construction*Please selectConcreteIron/Steel/AluminiumTiles/SlateMasonryAsbestosWoodEPS/Other (please provide details)Roof Construction - other answer Fire Protection - What fire protection is present and in working order?* No fire protection Sprinklers Smoke Detectors - monitored Smoke Detectors - not monitored Hose Reels - partial floor area Hose Reels - total floor area Fire Extinguishers Heat Detectors Fire Blankets Other Please provide more details Security - What security is provided?* No security Alarm - local alarm Alarm - monitored / back to base Deadlocks on doors Bars on windows Roller shutters CCTV Patrols Electronic key pad / swipe card access Security fencing External lighting Other Please provide more details Location - Which of the following best describes where the buildings are located?*Please selectMain or Suburban StreetWithin an Industrial ComplexOutside Metropolitan, regional or town boundariesWholly within a shopping centre (no external openings to outside centre)Within a shopping centre (with external openings)Within an Office Block (including ground or 1st floor)Within an Office Block (2nd floor or above)OtherPlease provide details Is the premises connect to town water* Yes No Fire Brigade - Distance to nearest Fire Brigade*Please selectLess than 5 km5-20 kmMore than 20 kmType of Fire Brigade*Please selectProfessional Manned 24 hoursProfessional Manned part timeOwn on site staff fire brigade Manned 24 hoursRural or country volunteer brigadeFlammable Goods - Are flammable goods stored on the premises?* No Yes What quantity?* In approved cabinets/bunded storage facilities?* Yes No Cover RequiredWhat cover do you require for this Situation?* Business Property Business Interruption Theft Money Glass Machinery Breakdown and Electronic Equipment Business PropertyDescription of Property Sum Insured*Stock Stock Sum InsuredAll Contents other than Stock All Contents other than Stock AmountFree-text Property Line 1 Free-text Property Line 1 answerFree-text Property Line 2 Free-text Property Line 2 AnswerFree-text Property Line 3 Free-text Property Line 3 AnswerTotal Sum InsuredOther Covers Other AmountRemoval of Debris Other Amount DebrisRewriting of Records Other Amount Rewriting of RecordsFlood No Yes Flood amount answerBusiness InterruptionSub-limit*Please selectInsurable Gross ProfitAnnual RevenueLoss of Rent ReceivableBusiness Interruption Amount*Other Covers Other AmountB.I Claims Preparation Costs B.I Claims Preparation Costs amountIndemnity Period* PayrollIf not insured 100% in Gross ProfitLoss of PayrollPlease details for loss of payrollDo you wish to provide further information?TheftDescription of Cover Sum InsuredLiquor Products Liquor Products Sum InsuredStock, other than tobacco or liquor Stock, other than tobacco or liquor Sum InsuredMachinery & Plant Machinery & Plant Sum insuredTheft (limited) without forcible and violent entry Theft (limited) without forcible and violent entry sum insured1st blank choice - Theft 1st blank choice - Theft sum insured2nd blank choice - Theft 2nd blank choice - Theft sum insuredOther Covers Other AmountDamage to rented premises Rented Premises Other AmountSeasonal increase period/s Seasonal Increase periods AmountDirectors & employees tools of trade and personal effects Directors & employees tools of trade - amountEmployee dishonesty Employee dishonesty - amountMoneyDescription of Cover Sum InsuredOn premises – Business Hours On premises – Business Hours Sum InsuredOn premises – Outside Business Hours On premises – Outside Business Hours Sum InsuredIn a locked safe Locked safe Sum InsuredIn Private Residence In Private Residence Sum InsuredBlank Money line 1 Blank line 1 answerBlank Money line 2 Blank line 2 answerGlassWhat glass cover do you require?*Please selectInternal glassExternal glassBoth internal & external glassDo you wish to add any specified glass items?* Yes No Specified Glass Items AnswerPlease specifyMachinery Breakdown and Electronic EquipmentSpecified Machinery Sum InsuredSpecified Machinery - line 2 Sum Insured - line 2Specified Machinery - line 3 Sum Insured - line 3Specified Machinery - line 4 Sum Insured - line 4Specified Machinery - line 5 Sum Insured - line 5Specified Machinery - line 6 Sum Insured - line 6Specified Electronic Equipment Sum InsuredSpecified Electronic Equipment - line 2 Sum Insured Electronic - line 2Specified Electronic Equipment - line 3 Sum Insured Electronic - line 3Specified Electronic Equipment - line 4 Sum Insured Electronic - line 4Specified Electronic Equipment - line 5 Sum Insured Electronic - line 5Specified Electronic Equipment - line 6 Sum Insured Electronic - line 6Optional Extras - Do you require cover for Deterioration of stock? Yes No Binder Agreement Coast Insurance Pty Ltd (ABN 44 108 154 829, AFSL 268726) (‘Coast’) distributes the product under a binding authority as agent for the Insurer. The Policy is underwritten by certain underwriters at Lloyd’s (‘Underwriters’) (proportion 100%). The Underwriters are collectively referred to as ‘We, Us, Our, the Insurer(s)’ in the Policy Duty of Disclosure Before You enter into an insurance contract, You have a duty to tell Us anything that You know, or could reasonably be expected to know, may affect Our decision to insure You and on what terms. You have this duty until We agree to insure You. You have the same duty before You renew, extend, vary or reinstate an insurance contract. You do not need to tell Us anything that: reduces the risk We insure You for; or is common knowledge; or We know or should know as an insurer; or We waive Your duty to tell Us about Please upload any documents/photos that will help with your submission Drop files here or Select files Accepted file types: jpg, gif, png, pdf, Max. file size: 24 MB, Max. files: 5.
