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General Information
*Required
 

Claims Information

In the past five (5) years, have you, or anyone else insured by the policy:

- Lodged more than (3) claims for loss, or

- Had claims made against you, or

- Lodges claims totalling more than $5,000?

Building Construction, Fire Protection and Security

Public Liability Section

Engage personnel provided through labour hire companies or organisations?
Undertake welding or hot cutting activities away from own premises?
Perform work at mine sites, either above or below ground?
Provide products or services intended for use in the mining industry?
Provide equipment on hire?
Assume liability under any agreement other than property rental agreements
Import any products into Australia?
Export any products to the USA or Canada?

Fire & Perils Section

Business Interuption

Theft Section

Money Section

Glass Section

Machinery Breakdown

Description of Property (make and model) and Sum Insured

Description of Property (make and model) and Sum Insured

Description of Property (make and model) and Sum Insured

Description of Property (make and model) and Sum Insured

Description of Property (make and model) and Sum Insured

Tax Investigation

If YES, cover is not available.

Other Sections

DECLARATION

This declaration must be completed and signed by or on behalf of the party applying for insurance. I/We

a) declare that:

i. the answers and information given by me/us in this Application are true and correct in all respects;

ii. no information has been withheld that would affect an insurers decision to accept this Application;

iii. where answers in this online application have not been competed by myself, they have been checked by me/us and I/we agree they are correct and true;

iv. I/we have read and understood the  Financial Services Guide and Privacy Statement;

v. if there was insufficient space to fully answer any questions, I/we have attached supplementary pages providing the additional information required.

b) authorise Wallace Risk Solutions Pty Ltd to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to these insurance covers, and any other insurances held by me/us and claims under those insurances.

Files must be less than 2 MB.
Allowed file types: gif jpg png txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml.