Great Wall Insurance Services



78740centerGreat Wall Insurance ServicesCLIENT ENqUIRY & FACT FIND FORMt: +613 9574-2833 f: +613 9574-2899The information you provide will help us find the right insurance for you. Please return it to your Great Wall Account Manager, or send it to us on enquiries@.auContact name(s): FORMTEXT ????? FORMCHECKBOX Commercial insurance ABN: FORMTEXT ????? FORMCHECKBOX Domestic insurance DOB: FORMTEXT ????? Retired: FORMCHECKBOX Yes FORMCHECKBOX NoCompany name: FORMTEXT ?????Risk address: FORMTEXT ?????Postal address: FORMTEXT ?????Description of business: FORMTEXT ?????Phone: FORMTEXT ?????Fax: FORMTEXT ?????E-mail: FORMTEXT ?????Current insurer & broker: FORMTEXT ?????Expiry date for current policy: FORMTEXT ?????Commencement date for new policy: FORMTEXT ?????Interested parties (landlord, bank, trustees, council): FORMTEXT ?????Any claims in the past 5 years? FORMCHECKBOX Yes FORMCHECKBOX NoProvide information on claim amount, year, type of claim: FORMTEXT ?????Years in business: FORMCHECKBOX 3 -5 yearsPrevious business experience: FORMTEXT ????? FORMCHECKBOX 0 – 2 years FORMCHECKBOX 5+ yearsHave you (or your associates) been convicted of any criminal offence or been declared bankrupt?Has any insurer in respect of any insurance policy held (by you, your partners or directors) ever:Refused to renew / cancelled or terminated a policy? Refused a claim or required an increase premium under the policy?Imposed special conditions under the policy? FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoriskESTIMATED cover REQUIRED ($)Additional comments:Fire & perils – PropertyBuildingContents and stock$ … FORMTEXT ?????$ … FORMTEXT ?????Business interruptionGross profitIndemnity period$ … FORMTEXT ?????Months … FORMTEXT ?????Burglary / TheftTobacco / CigarettesStock (ex. Tobacco/Cigs)Other Contents$ … FORMTEXT ?????$ … FORMTEXT ?????$ … FORMTEXT ?????LiabilityLimit of public indemnity Product liabilityImport activities Property owner FORMCHECKBOX $5m FORMCHECKBOX $10m FORMCHECKBOX $20m FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Yes FORMCHECKBOX NoGlass FORMCHECKBOX Yes FORMCHECKBOX NoMoney$ … FORMTEXT ?????Machinery $ … FORMTEXT ?????Electronic equipment$ … FORMTEXT ?????Other $… FORMTEXT ?????$… FORMTEXT ?????$ … FORMTEXT ?????$ … FORMTEXT ?????Thank you for providing this information. An Account Manager will be in touch with you to discuss your insurance needs. If you have time to fill in the next page, this will help us provide you with a more accurate quote. Insured Premises / business propertyYear built (approx): FORMTEXT ?????Year rewired: FORMTEXT ?????No. of stories: FORMTEXT ?????(Office use) – est. replacement cost: FORMTEXT ?????Flood prone area: FORMCHECKBOX Yes FORMCHECKBOX NoAsbestos: FORMCHECKBOX Yes FORMCHECKBOX NoDoes the building contain EPS (expanded polystyrene)?Heritage/Trust listed: FORMCHECKBOX Yes FORMCHECKBOX NoApprox size (sqm): FORMTEXT ?????Ground floor FORMCHECKBOX Concrete FORMCHECKBOX Wood FORMCHECKBOX Other ( FORMTEXT ????? ) FORMCHECKBOX No EPS FORMCHECKBOX 20 – 29%Second floor FORMCHECKBOX Concrete FORMCHECKBOX Wood FORMCHECKBOX Other ( FORMTEXT ????? ) FORMCHECKBOX 1 – 14% FORMCHECKBOX >30%Roof FORMCHECKBOX Concrete FORMCHECKBOX Metal FORMCHECKBOX Tile FORMCHECKBOX Other ( FORMTEXT ????? ) FORMCHECKBOX 15 – 19%Walls -1st floor FORMCHECKBOX Concrete FORMCHECKBOX Brick FORMCHECKBOX Wood FORMCHECKBOX Iron FORMCHECKBOX Other ( FORMTEXT ????? )Walls -2nd floor FORMCHECKBOX Concrete FORMCHECKBOX Brick FORMCHECKBOX Wood FORMCHECKBOX Iron FORMCHECKBOX Other ( FORMTEXT ????? )Any other information about the premises: FORMTEXT ?????insured premises protection – FIRE Fire extinguishers FORMCHECKBOX Yes (# FORMTEXT ?????) FORMCHECKBOX No Fire alarm FORMCHECKBOX Monitored FORMCHECKBOX UnmonitoredFire blanket FORMCHECKBOX Yes (# FORMTEXT ?????) FORMCHECKBOX No FORMCHECKBOX Battery FORMCHECKBOX Hard WiredFire hose FORMCHECKBOX Yes (# FORMTEXT ?????) FORMCHECKBOX NoSprinklers FORMCHECKBOX No FORMCHECKBOX Town waterSmoke detector FORMCHECKBOX Yes (# FORMTEXT ?????) FORMCHECKBOX No FORMCHECKBOX Single supply FORMCHECKBOX Dual supplyOther (provide details): FORMTEXT ?????INSURED PREMISES PROTECTION - SECURITYBurglar alarm FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX Local alarm FORMCHECKBOX Private line FORMCHECKBOX Security companyDeadlocks on doors FORMCHECKBOX Yes FORMCHECKBOX NoBars on windows FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX SecuredCCTV FORMCHECKBOX Yes FORMCHECKBOX NoSecurity Patrol FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX UnsecuredShutters FORMCHECKBOX Yes FORMCHECKBOX NoOther (provide details): FORMTEXT ?????CONTENTS / STOCKStock on premises in open air (trailers, signboards): FORMCHECKBOX Yes FORMCHECKBOX NoCustomer’s goods onsite: FORMCHECKBOX Yes FORMCHECKBOX NoPhysical assets stored offsite: FORMCHECKBOX Yes FORMCHECKBOX NoHigh value electronic equipment: FORMCHECKBOX Yes FORMCHECKBOX NoFOOD SAFETYDeep frying FORMCHECKBOX Yes FORMCHECKBOX NoFilters cleaned: FORMCHECKBOX Weekly FORMCHECKBOX MonthlyExhaust flue cleaned: FORMCHECKBOX 6 monthly FORMCHECKBOX AnnuallyCleaned by: FORMCHECKBOX Staff FORMCHECKBOX Commercial contractor Wok frying FORMCHECKBOX Yes FORMCHECKBOX No PRIVACY STATEMENTGreat Wall Insurance Services is committed to protecting your privacy. We use the information you provide to advise about and assist with your insurance needs. We provide your information to insurance companies and agents that provide insurance quotes and offer insurance terms to you or the companies that deal with your insurance claim (such as loss assessors and claims administrators). Your information may be given to an overseas insurer (like Lloyd’s of London) if we are seeking insurance terms from an overseas insurer, or to reinsurers who are located overseas. We will try to tell you where those companies are located at the time of advising you. We do not trade, rent or sell your information. If you don’t provide us with full information, we can’t properly advise you, seek insurance terms for you, or assist with claims and you could breach your duty of disclosure. For more information about how to access the personal information we hold about you and how to have the information corrected and how to complain if you think we have breached the privacy laws, ask us for a copy of our Privacy Policy. ................
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