Broker DetailsTick this box if you are an insurance broker - Yes I am an insurance broker Name First Name Surname Brokerage Name Branch / Location Email Address Mobile Number Insured's DetailsFull name of insured Website Address SituationInception/Expiry DateLimit of Indemnity $5,000,000 $10,000,000 $20,000,000 Care, Custody & Control Sublimit $50,000 $100,000 $250,000 Excess $1,000 $2,500 $5,000 $10,000 Number of years in business Number of years experience Estimated annual turnoverEstimated annual payrollBusiness Activities/DescriptionShow percentage of work performed in each stateNSWPlease enter a number from 0 to 100.VICPlease enter a number from 0 to 100.QLDPlease enter a number from 0 to 100.SAPlease enter a number from 0 to 100.ACTPlease enter a number from 0 to 100.TASPlease enter a number from 0 to 100.WAPlease enter a number from 0 to 100.NTPlease enter a number from 0 to 100.(Validation only)Total Percentage(must be 100%)Do you use sub-contractors or labour hire personnel? Yes No Estimated annual paymentsIf yes, do they have their own liability insurance? Yes No Estimated annual payments Does the Insured enter into any hold harmless/contractual obligations Yes No Claims details - summary last 5 yearsEver been declined insurance? Yes No CommentsQUOTATION PURPOSES ONLY and could be subject to a satisfactorily completed Proposal Form.CAPTCHAEmailThis field is for validation purposes and should be left unchanged. Δ