INSURANCE APPLICATION FORM Company Name Business/ Trading Name Business address Postal address Contact Name Telephone phone Mobile phone Email address Nature of Business Number of years in business House keeping BUILDING CONSTRUCTION DETAILS (Concrete, gib board, wood, mixed, steel, iron etc.) Walls Roof Floor Age No. of storey Any other information SECURITY PROTECTION (Put Y if yes and N if no) Alarm Monitored to phone/security company Security Patrol Security lights CCTV Fence Bars/Grills on windows/ doors Roller Shutter Bollard Deadlock Safe * Note: For pubs/bars/gaming machines where higher money cover is required, please ask for* make, mode sr. no. of safe, money rating and whether safe is bolted to ground or not FIRE PROTECTION(Put Y if yes and N if no) Fire Hose Sprinklers- Smoke Fire Extinguishers reels Alarm Alarm Y N Y N Y N Y N Y N No. of fat fryers Fryer Capacity Fire blanket Note:_ For takeaways and food outlets where deep fat frying is done, please ask for How often filters and ducts are cleaned and is there contract for cleaning or done by in-house staff. Any other information-good/adverse feature of risk, neighboring business etc. Fundagroup Insurance Brokers Limited Page 1
Building: Please ask for latest Insurance Purpose Valuation (less than 2 years old) Year of Construction Town water/ Tank water Interested party-bank/ Finance company Replacement value RV Indemnity Value IV Inflationary provision RV / IV Demolition Current valuation* available? Yes or No Natural Disaster cover required Yes No * Please note for Building insurance cover, insurance companies require Insurance Purpose Valuation less than 2 years old (from the date of application of insurance) Any loss (whether insured or not) and/or claim(s) made in last 5 years? If yes, please provide detail below: Plant & Contents Tenants Improvements Landlords Fixtures fittings Plant, machinery & contents Stocks Frozen food Money A/B Natural Disaster Cover Y / N Any loss (whether insured or not) and/or claim(s) made in last 5 years? If yes, please provide detail below: Business Interruption Gross Profit Including wages Annual Wages Loss of Rents Claims Preparation AICOW Indemnity Period (months) - 12/18/ 24 Natural Disaster Cover Y / N Any loss (whether insured or not) and/or claim(s) made in last 5 years? If yes, please provide detail below: Fundagroup Insurance Brokers Limited Page 2
LIABILITY: Annual Turnover in past 12 months Expected Turnover in this financial year Number of employees Is any work done away from main Business premises Yes / No Does your business involve dangerous operations such as handling/storing hazardous substances, use of naked or open heat sources, Welding, excavation of land, working at heights? Yes / No Does your business operate outside NZ in any way Yes / No Does your business discharge dangerous or toxic substances? Yes / No Do you store other people s property at your business? If yes, please provide type, value and location of those items Yes / No LIMIT OF INDEMNITY General Legal Liability $1M / $2M / $5M / $10M Bailment $250,000 Defective Design $250,000 Forest & Rural Fires Act $250,000 Service & Repair & WOF $250,000 Exemplary Damages extension in NZ (Y/N) (under General Legal Liability) $250K Statutory Liability $250K / $500K / $1M Employers Liability $250K / $500K / $1M Fundagroup Insurance Brokers Limited Page 3
HOUSE INSURANCE- If pre 1950, Please fill additional questionnaire: Name of Property owner: Address of property: Built up sq. mtr floor area Year built Replacement sum insured Owner occupied/ Rental Town water/ Tank water Interested Party Owner s DOB Alarmed Monitored Dead locks Rental* extension If Yes, please provide weekly rent Any loss (whether insured or not) and/or claim made in last 5 years? If yes, please provide detail below: *Landlord s Rental extension ( covers Malicious damage by tenants & Loss of rents) For Landlord extension, please be aware that there should be written tenancy agreement; deposit lodged with Tenancy commission/tribunal, 3 monthly inspections should be carried out. CONTENTS INSURANCE: Name of Insured: Address of property: Owner s DOB Town water/ Tank water Alarmed Monitored Dead locks Specified items over $3000*. Any other information Any loss (whether insured or not) and/or claim made in last 5 years? If yes, please provide detail below: *If cover is required for specified item, please provide list along with proof of purchase/valuation Please note standard Jewelry cover is limited to $10,000 OR LESS by most insurers Fundagroup Insurance Brokers Limited Page 4
COMMERCIAL & PRIVATE MOTOR INSURANCE: Loss of Use cover can be added if requested for Commercial motor. Please check number of weeks cover required and rental amount per day Year Make Model Rego. no. Market Value Interested Party DOB of principal driver Exclude driver under 25 Named driver Any claim made in last 3 years? If yes, please provide detail below: AVERAGE CLAUSE This clause is applicable to all losses where there is underinsurance provided the Average Clause is shown as applicable under Application of Warranties & Additional Conditions in the Schedule, other than buildings or plant where at inception or renewal of this Certificate there is a valuation that is no more than 2 years old and the sums insured are no less than the valuation. To comply with Section 16 of the Insurance Law Reform Act 1985 the meaning of Subject to Average is set out below: The Meaning of Subject to Average (1) Your insurance policy contains a provision making it subject to average. (2) That provision will have effect only if the property insured under the policy is underinsured at the time of loss. (3) If the property insured under the policy is underinsured at the time of loss, the following rules apply: (a) If you suffer a total loss, the provision will have no effect: (b) If you suffer a partial loss, the maximum amount that you may recover will bear the same proportion to your actual loss as the amount for which the property is Insured bears to the full value of the property: (c) Whatever your loss, in no case will you be entitled to recover more than the amount for which the property is insured. Example: Your property is worth $40,000. You insure it for $20,000. You suffer a loss of $10,000. If your policy is subject to average, the maximum amount that you may recover will be $5,000 Fundagroup Insurance Brokers Limited Page 5
Questionnaire and Declaration You means You or Your any family members, de facto partner, business partners, directors, trustees and/or beneficial owners, managers, or any other person or entity to be covered by this insurance: In the last 5 years (i) Has any insurer ever refused to insure you on standard terms, or refused to renew your Yes No insurance on standard terms (ii) Has any insurer ever refused to pay your insurance claim? Yes No (iii) Have you made any insurance claim in last 5 years Yes No (iv) Been bankrupt? Yes No (vi) Engaged in any criminal activity or had any criminal convictions, acquittals or diversions, or have any criminal prosecutions pending? Yes No If yes, please provide details: Your Duty of Disclosure You have a duty to tell the insurance company when You apply for, renew, extend, vary, or reinstate a contract of insurance. You have a legal duty to disclose every matter that You know, or could reasonably be expected to know, that is relevant to the prudent insurers to decide whether to accept the risk of the Insurance, and if so, on what terms and at what cost. Failure to comply with Your duty of disclosure may result in a claim being declined, or Your insurance being void from the beginning. All information must be complete and accurate and may include any information not directly asked for above. Examples of what you must tell include: anything that increases the risk of a claim, any criminal offending or convictions, any previous insurance claims, any refusal by any insurer to insure/ continue to insure you on standard terms during the currency of policy or on renewal. Pursuant to the Privacy Act 1993 This proposal collects personal information about you, in order to evaluate your insurance requirements and for the purpose of arranging insurance quote(s) along with terms and conditions of cover. The information collected will be shared with and held by the Insurance Company (ies) and its authorized representatives. Failure to provide any personal information requested may result in your application for insurance being declined. You have the right of access to, and correction of, this personal information subject to the Privacy Act 1993. Please read the declaration before signing this application: 1. Subject to any rights, I/We under the clean slate Act, confirm that the answers given in this Application Form are true and correct and I/We have not withheld any details of previous claims, including uninsured losses or any other material fact (e.g. bankruptcy, criminal offences) likely to affect acceptance of this application. 2. This proposal shall be the basis of contract between me/us and the insurance, company and I am/we are willing to accept cover subject to Insurance company s policy terms, conditions, exclusions and any special terms they may require. 3. I/We authorize the disclosure to the Company or its appointed advisors or personal information held by another party regarding this application or my/our previous/ongoing insurances. 4. I/We agree to the Company releasing to other parties information regarding this application or my/our previous/ongoing insurance. 5. I/We have read and understood the Your Duty of Disclosure section of the Application Form. 6. I/We understand that this Declaration will also apply to any future private/domestic insurances I have with the Company unless Superseded by a new Client Application Form. Name of the Authorised signatory Designation.. Company Name.. Signature.. Date. Fundagroup Insurance Brokers Limited Page 6