NAME OF BROKING FIRM NAME PHONE CONTACT DETAILS FAX EMAIL WEBSITE BROKER INFORMATION YOUR DUTY OF DISCLOSURE Before You enter into a contract of general insurance with an insurer, You have a duty, under the Insurance Contracts Act 1984, to disclose to the insurer every matter which you know or could reasonably be expected to know, is relevant to the insurer s decision whether to accept the risk of the insurance and if so, on what terms. You have that same duty to disclose those matters to us before you renew, extend, vary or reinstate a contract of insurance. Your duty however does not require disclosure of a matter: that diminishes the risk to be undertaken by the insurer; that is common knowledge; that the insurer knows, or in the ordinary course of business as an insurer, ought to know; as to which compliance with your duty is waived by the insurer NON-DISCLOSURE If you fail to comply with your duty of disclosure, the insurer may be entitled to reduce its liability under the contract in respect of a claim or may cancel the contract. If your non-disclosure is fraudulent, the insurer may also have the option of avoiding the contract from its beginning. RESERVING POLICY DATE PROP RECEIVED: ACTIONED BY: IF NO, REASONS: DATE 26N QUOTE SLIP PREPARED: CLIENT REFERENCE: OFFICE USE ONLY PROPOSAL MEETS 26N R I REQUIREMENTS?: 26 NORTH QUOTE SLIP PREPARATION PREPARED BY: Ph: (07) 4040 4426 Fax: (07) 4040 4400 Email: matt@26north.com.au 1 of 6
CONTACT PERSON(S) PHONE NUMBERS EMAIL ADDRESS WEBSITE HOME MOBILE BUSINESS FAX CLIENT INFORMATION POSTAL ADDRESS NAME OF BODY CORPORATE STRATA PLAN NO.: REGISTERED FOR GST ITC (INPUT TAX CREDIT) PERCENTAGE ABN LENGTH OF OPERATION RISK MANAGEMENT CURRENTLY EMPLOYED BY INSURED INTERESTED PARTY (If insufficient space, please attach separate list) (eg. Risk manager onsite / regular fire drills / good maintenance etc) 1) TYPE OF INTEREST 2) TYPE OF INTEREST 3) TYPE OF INTEREST IS THE PROPERTY CURRENTLY INSURED? CURRENT INSURER CURRENT BROKER (if applicable) EXPIRY DATE / / IF YES, APPROX PREMIUM (Excl. GST & SD) PLEASE ADVISE CURRENT EXCESS CURRENT CYCLONE EXCESS SPECIAL CONDITIONS IMPOSED IF NO, PLEASE ADVISE INCEPTION DATE from 4pm EST / / to 4pm EST / / ADDITIONAL EXCESS OPTION REQUIRED? [ ] 20,000 [ ] 50,000 [ ] OF SUM INSURED, SPECIFY : Ph: (07) 4040 4426 Fax: (07) 4040 4400 Email: matt@26north.com.au 2 of 6
INSURANCE INFORMATION MATERIAL LOSS / DAMAGE LOCATION OF THE PROPERTY OCCUPANCY DETAILS OF PREMISES OWNER OCCUPIED: LONG TERM LET: SHORT/HOLIDAY LET: : LONGITUDE/LATITUDE TO 3 DEC. PLACES ELEVATION (METRES ABOVE SEA LEVEL) REFER TO GOOGLE EARTH FOR COORDINATES LATITUDE: LONGITUDE: METRES A.S.L GOOGLE EARTH SCREENSHOT ATTACHED? LOCAL GOVERNMENT COUNCIL? DISTANCE TO SHORELINE (IN METRES) SUMS INSURED BUILDING SUM INSURED REMOVAL OF DEBRIS COMMON CONTENTS SUM INSURED CATASTROPHE COVER LOSS OF RENT LOT OWNER IMPROVEMENTS INDEMNITY PERIOD MONTHS CLAIMS PREPERATION COSTS PUBLIC LIABILITY OFFICE BEARERS LIABILITY VOLUNTARY WORKERS PA EMPLOYEE DISHONESTY/FIDELITY MACHINERY BREAKDOWN LEGAL EXPENSES AUDIT EXPENSES FLOOD COVER STORM SURGE CONSTRUCTION NUMBER OF STOREYS: WALLS [ ] BRICK [ ] CONCRETE [ ] TIMBER [ ] IRON ROOF [ ] CONCRETE [ ] IRON [ ] TIMBER FLOORS [ ] CONCRETE [ ] TIMBER LIFTS: POOLS: SPAS: CINEMA: GYM: TENNIS COURT: PLAYGROUNDS: RESTAURANT/CAFÉ: WATER FEATURES LAKE/POND/WATERWAY BOARDWALK: PONTOONS/MARINA: NUMBER OF UNITS: FACILITIES: IF YES TO ABOVE, PLEASE SPECIFY OF TOTAL BUILDING AREA ANY EPS/SANDWICH FOAM? ARE THERE ANY PARTICULAR REMOVAL OF DEBRIS REQUIREMENTS FOR THIS PROPERTY? IF YES, PLEASE SPECIFY: (LOCATION, CONSTRUCTION ETC) [ ], SPECIFY: [ ], SPECIFY: ANY ASBESTOS? IF YES TO ABOVE, PLEASE SPECIFY OF TOTAL BUILDING AREA [ ], SPECIFY: AGE OF THE BUILDING? BUILT: [ ] 10 [ ] 11-25 [ ] 26-50 [ ] > 51 [ ] 10 [ ] 11-25 [ ] 26-50 [ ] > 51 Ph: (07) 4040 4426 Fax: (07) 4040 4400 Email: matt@26north.com.au 3 of 6
SAFETY AND PROTECTION INSURANCE INFORMATION MATERIAL LOSS / DAMAGE DISTANCE (KM) AND NAME OF NEAREST MANNED FIRE STATION IF YES, IS THERE A MAINTENANCE AGREEMENT IN PLACE? EXTINGUISHERS TYPE: DATE LAST SERVICED HOW MANY: / / HOSE REELS? FIRE BLANKETS? SPRINKLER SYSTEM? IF YES PLEASE DESCRIBE PARTIAL COVERAGE: AUTOMATIC FIRE ALARM AND/OR SMOKE ALARM? CONNECTED TO FIRE STATION? [ ] TOTAL AREA OF PREMISES [ ] PARTIAL CONNECTED TO ALARM MONITORING COMPANY? NON SMOKING POLICY? LOCAL FIRE ALARM ONLY? ARE THE PREMISES CONNECTED TO TOWN RETICULATED WATER SUPPLY? DEADLOCKS AND/OR PADLOCKS TO ALL EXTERNAL DOORS? SECURITY SCREENS/BARS OR GRILLS TO ALL EXTERNAL WINDOWS? KEY LOCKS? BURGLAR ALARMS IF YES, WHAT TYPE?: [ ] BACK TO BASE (DEDICATED LINE) [ ] GSM [ ] AUDIBLE LOCAL ALARM WHICH OF THE FOLLOWING ARE PRESENT AND ACTIVATE THE ALARM? [ ] HEAT SENSORS [ ] PANIC BUTTONS [ ] MOTION DETECTORS (PIR) [ ] IR BEAM [ ] CCTV SENSOR CAMERAS [ ] : DOES YOUR BUILDING HAVE SECURE/GATED VEHICLE ENTRY? DOES YOUR BUILDING HAVE SECURE/GATED PEDESTRIAN ENTRY? DOES YOUR BUILDING HAVE PERIMETER FENCING? DOES YOUR BUILDING HAVE SECURITY LIGHTING? DOES YOUR BUILDING HAVE SECURITY WATCHMAN PATROLS? VALUABLES SAFE? HOW MANY? MANUFACTURER: MANUFACTURER: YEAR OF MAKE: YEAR OF MAKE: TORCH/DRILL RESISTANT? TORCH/DRILL RESISTANT? TIME DELAY LOCKS? TIME DELAY LOCKS? WASTE DISPOSAL METHOD: ITEMS ON PREMISES IS ANY COMMERCIAL COOKING DONE ON THE PREMISES? IF YES, THERMOSTAT CONTROLLED? ARE INFLAMMABLE LIQUIDS OR EXPLOSIVES STORED ON THE PREMISES? IF YES, PLEASE LIST TYPES AND HOW MUCH (LITRES/KILOGRAMS)? ARE THEY STORED IN [ ] TANKS [ ] DRUMS [ ] BOTTLES ARE THEY KEPT IN APPROVED FLAMMABLE GOODS CABINET OR STORE? IS THE STORE [ ] INTERNAL [ ] EXTERNAL IS IT BUNDED? Ph: (07) 4040 4426 Fax: (07) 4040 4400 Email: matt@26north.com.au 4 of 6
INSURANCE INFORMATION MATERIAL LOSS / DAMAGE STORM/WATER PERILS IS FLOOD REQUIRED? IS STORM SURGE REQUIRED? (IF REQUIRED, PLEASE ATTACH SUPPORTING INFORMATION) (NOTE: THESE COVERS ARE SUBJECT TO AVAILABILITY) DOES THE PROPERTY SIT ON THE HIGH OR LOW SIDE OF THE ROAD? [ ] HIGH [ ] LOW DOES THE PROPERTY SLOPE FROM FRONT TO BACK? ARE THERE ANY RIVER OR CREEK SYSTEMS WITHIN 200 METRES OF THE PREMISES? HAS THE PREMISES SUFFERED ANY FLOOD OR STORM DAMAGE LOSSES IN THE LAST 5 YEARS? IF YES, VALUE OF DAMAGE AND DATE(S) OF LOSS DOL: / / DOL: / / DOL: / / DOL: / / DO YOU HAVE ANY PIECE OF MACHINERY GREATER IN VALUE THAN 500,000 AUD? IF YES, PLEASE SPECIFY VALUE AND HOW MANY IN THE EVENT OF LOSS WOULD ANY OF YOUR MACHINERY HAVE TO BE SOURCED FROM OVERSEAS? IF YES, EXPECTED REPLACEMENT TIME? IF INSURING HIGH VALUE MACHINERY, HAS THE INSURED TAKEN ANY STEPS TO MITIGATE THE CHANCE OF WATER DAMAGE TO MACHINERY (IE. ADEQUATE STORM DRAINS) IF YES, PLEASE ADVISE STEPS TAKEN: No.: WHAT TYPE OF GUTTERING DOES THE PROPERTY HAVE? [ ] CONVENTIONAL GUTTERING [ ] BOX GUTTERING DOES THE PROPERTY HAVE ANY RUN OFF DRAINAGE? IF YES, PLEASE ADVISE: DOES THE PROPERTY HAVE A BILGE PUMP? IF YES, WHAT TYPE? [ ] ELECTRIC [ ] PETROL [ ] DIESEL DOES THE ROOF CONTAIN SKY LIGHTS? IF YES, HOW MANY? ADJOINING PREMISES NORTH SOUTH EAST WEST PLEASE ATTACH ANY ADDITIONAL INFORMATION WHICH MAY ASSIST DESCRIBING THE RISK ON SEPARATE DOCUMENT Ph: (07) 4040 4426 Fax: (07) 4040 4400 Email: matt@26north.com.au 5 of 6
DUTY OF DISCLOSURE Has any insurer in respect of any insurance policy held by you, your partners and/or directors ever: 1) Been refused renewal or had a policy cancelled or terminated? 2) Had a claim refused or required an increased premium under the policy? 3) Had special conditions imposed under the policy? 4) Committed any criminal offences or been declared bankrupt? 5) Had any claims in the past 5 years (on any property)? 2009-2010 2010-2011 2011-2012 2012-2013 2013-2014 6) Do you use or have any radioactive, explosives, flammable, toxic, corrosive or potentially dangerous goods? 7) Are any of your premises, plant or machinery not in good repair, and are any statutory requirements not met? 8) Are there any other matters you should disclose (see 'Your Duty of Disclosure') If you have answered "Yes" to any of the above, please provide further information below: CLAIMS MANAGEMENT CLAIM INCIDENT ACTION TAKEN PREVENTATIVE AND/OR CORRECTIVE ACTION TAKEN CLIENT SIGNATURE: DATE: ACKNOWLEDGEMENT BROKER SIGNATURE: DATE: Ph: (07) 4040 4426 Fax: (07) 4040 4400 Email: matt@26north.com.au 6 of 6