Unoccupied or Vacant Property - Property & Liability Form 1Broker & Insured Details2History3Situation4Duty of Disclosure 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 definitionsBroker 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 Premises been unoccupied?*Please selectUp to 2 Years3-5 years5 years or moreIs the building partially tenanted?* No Yes Please provide the percentage of the building that is occupied* Please list the activities carried out*Is the property in receivership / or has the Insured been in administration / receivership?* No Yes Is the property under possession of a mortgagee?* No Yes What are the future plans for this property?*About the PropertyIs the property in a good state of repair and structurally sound?* No Yes Are the Premises likely to undergo any building works, renovation, refurbishment, redecoration or demolition during or after the period of insurance?* No Yes (please specify below) Renovation / refurbishment / decoration* No Yes Please describe the works to be carried out*Value of works carried out* Demolition (application to be made or approval pending)* No Yes Demolition (application approved)* No Yes Demolition (commenced)* No Yes Is the property professionally managed?* Yes No ClaimsHas 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 SituationSituation Address* Street Number (include unit number, if applicable) Street Name Suburb State Postcode Please select the appropriate description of the situation*Please selectVacant residential block of land onlyVacant residential free-standing house (including land)Vacant residential unit within complexVacant commercial block of land onlyVacant commercial free-standing building (including land)Vacant commercial unit within complexVacant Rural PropertyOther (please provide details)Other (please provide details)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 Is the property heritage listed?* No Yes (please provide details) Please provide details Does the premises have any of the following: A lift, Escalator, an ATM, or Solar Panels?* A lift Escalator An ATM Solar Panels None of the above Fire Protection - What fire protection is present and in working order?*Tick all that apply 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?*Tick all that apply 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 property is 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 Is the premises connected to electricity?* Yes No Is the property connected to gas?* 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 Glass Public and Products Liability Business PropertyDescription of Property Sum Insured*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 AmountOther Covers (2) Other Amount (2)Blank Blank amountGlassWhat 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 specifyPublic and Products LiabilityDo you require cover for Property Owner's liability?* 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 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.
