Yes No
Are you an Insurance Broker?
In what capacity are you applying for this insurance ?   
Intrested Party Named Insured
In what capacity is the landlord to be noted?
Occupation Licensed Brothels

Location of Business
Street Number/Name
Suburb
State
Postcode

Building Construction Details
Year Built
Yes No
Rewired
When was the building rewired?
Replumbed
When was the building replumbed?
Heritage Listed or Overlay
Walls
Floor
Roof
Number of Stories
Yes No
Sprinklers Installed
Hose Reels
Fire Alarm
Thermal/Smoke Detectors
Fire Extinguishers
Service/Maintenance Agreements in Place

Insurance Requirements
Building Sum Insured Required $
Removal of Debris Cover Required $
 

Public & Products Liability
Annual Revenue/Turnover $
Number of Employees
Estimated Wages $
Annual Rental Income $
Limit of Liability Required
Yes No
Do You Require Business Interruption Insurance ?
Sum Insured $
Indemnity Period
Do you require cover for Additional Increased Cost of Working?
Level of Cover Required $
Do you require cover for Claims Preparation Costs?
Level of Cover Required $
Do you require cover for Outstanding Accounts Receivable?
Level of Cover Required $
Do you Require Cover for Loss of Rent?
Annual Rental Income to Insure $
Yes No
Do you require Contents Cover?
Contents Sum Insured Required $
Stock Sum Insured Required $
Do you want to cover Theft of Contents or Stock?
Contents Sum Insured Required $
Stock Sum Insured Required $
Are the premises fitted with an Alarm?
Type of Alarm
Are there Watchman Patrols?
Are there Deadlocks fitted on all external doors ?
Are there Window Locks/Bars or Grills Fitted?
Theft without forcible entry $
Do you want cover for Lost/Stolen Money ?
Do You have ATM Facilities?
Blanket Cover Amount Required?
Do you want cover for Glass Breakages ?
Do you need to provide Cover for an Unrelated Landlord?
Name of Landlord
Building Sum Insured Required $
Annual Rental: $
Does the Landlord require cover for Loss of Rent?
 
Do you Require Cover for any of the following? Yes No
Machinery Breakdown
General Property
Employment Practices
Professional Liability
Electronic Equipment Cover
Employee Dishonesty
Transit
Statutory Liability