On-line Industrial Special Risks Insurance


Thank you for considering our on-line industrial special risks insurance service.   Because Greater National Group is an insurance broker, not an insurance company, we will process your application with major insurance companies in order to find the right industrial special risks insurance for you.deal.

Please fill in the following form as fully as possible, then click 'submit' at the end of the form.
You can use the TAB key to move to the next field. We will respond with your terms as soon as we have researched the market for the right available deals that fit your requirements.


1a. Current Insurer:
1b. Current Policy Expiry Date:
2. Risk Details
Situation Occupation Construction Asset Value
$
$
$
$
$
$
Total Asset Value: $
3. Consequential Loss - Declared Value
Current Insured Gross Profit: $
Rent Receivable: $
Insured Payroll: $
Total: $
Claims Experience Details
4. Material Loss Or Damage & Consequential Loss
Type of Loss Year Amount
$
$
$
$
Limits Of Liability
5a. Material Damage $
5b. Consequential Loss $
Indemnity Period months
5c. Sub-Limits of Liability
Material Damage Section
Description Tick if Required? Limit ($)
Burglary
Theft
Money on premises during business hours
Money in transit
Money on premises outside business hours
Money whilst contained in safe
Money in Private Residence
Removal of Debris
Rewriting of Records
Personal Property of Directors/Employees
Accidental Breakage of Glass Replacement Value
Accidental Damage
Architects Fees
Fire Extinguishment Costs
Cost of Temporary Protection
Cost of Replacing Locks and Keys
Extra Cost of Reinstatement
Any other limits
Consequential Loss
Professional Fees
Payroll (Based upon Dual Wages Method)
Additional Increase Cost of Working
Suppliers and Customers Premises
Wages in Lieu of Notice
Any other limits
Total
General Deductibles
6. Standard Excess Required $


Duty of Disclosure:
Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?
Yes No
If so, please provide details:
I/We hereby declare that:
My/Our attention has been drawn to the Important Notices accompanying this form and further I/we have read these notices carefully and acknowledge my/our understanding of their content. The above statements are true, and I/we have not suppressed or mis-stated any facts and should any information given by me/us alter between the date of this form and the inception date of the insurance to which this relates I/we shall give immediate notice thereof. I/We authorise GNG and the Insurer to collect or disclose any personal information about another individual (for example, an employee, or client), I/we declare that the individual has been or will be made aware of that fact and the Privacy Policy. I/We also confirm that I/we am/are authorised to act for and on behalf of all persons who may be entitled to indemnity under any policy which may be issued pursuant to this form and I/we complete this form on their behalf.
Any other comments, requests or relevant information you need to add:
Contacting you about your quote:
In order to select the most appropriate cover for you, it may be important to discuss quote details in person. Please leave a contact phone number and best time to call to facilitate this.
Your full name:
Company/Business/Name of Applicant to be Insured:
ABN:
Your phone number (please include area code):
Your mobile phone number:
Best time(s) to call:
Please send my quote by (select at least one):
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Your email address:
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