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ISR Proposal From

Download PDF Form

Insured

Insured Name(Required)

ABN(Required)

Business Description(Required)

Contact

Website

How many situations require cover under this policy(Required)

Broker

Brokerage

Intermediary Number

Account Manager Name

Broker Phone Number

Account Manager Email

Broker Mobile Number

Schedule of Questions / General Information

In the last 5 years, Have You or any Director, Manager or Partner of the business

Had insurance declined or cancelled?(Required)

Yes

No

Please provide more information

Had any special conditions or excess imposed on your insurance?(Required)

Yes

No

Please provide more information

Had any claim declined?(Required)

Yes

No

Please provide more information

Been declared bankrupt or had any business placed in adminstration?(Required)

Yes

No

Please provide more information

Been charged and convicted with any criminal offence?(Required)

Yes

No

Please provide more information

Has the insured incurred a claim in the past 5 years?(Required)

Yes

No

if yes; new line per claim.

Has the insured suffered a loss >$100,000 ever?(Required)

Yes

No

if yes; Details

Situation Details

Situation #(Required)

Street Number

Street Name

Suburb(Required)

State(Required)

Postcode(Required)

Primary occupancy at this address(Required)

Secondary occupancy at this address.

Construction

# of storeys

Walls

Internal frame

Roof Covering

Roof Frame

Floors (list all)

Age of Building

Last renovation (cost and details)

If more than 1 storey, list the details below

Floor Level

Age of Building

Last renovation (cost and details)

Sandwich pannelling?

Yes

No

Type of panel?

Amount of panel by floor space %?

Is there asbestos on site? Where

Heritage Listed?

Yes

No

Electrical Infrastructure

Age of Main Switchboard

When was the last inspection?

Are all appliances subject to test and tag as per australian standard?

Yes

No

Are contractors engaged for annual inspections/testing.

Yes

No

Is there any cooking on site?

Yes

No

Are contractors engaged to clean exhaust ducting, flues and filters?

Yes

No

Frequency?

Is there forklifts in use on site?

Yes

No

Battery or LPG

Dedicated charging station clear of combustible construction or commodity

Are spare gas cylinders stored within locked cabinets, clear of hazard?

Is there charging of any Lithium ION batteries/portable equipment on site?

Yes

No

Dedicated charging station clear of combustible construction or commodity

Flammable / Hazardous Materials Storage & Handling

Yes

No

Stored correctly according to Australian Standard?

Yes

No

Fire Detection & Protection

Sprinkler System?

Yes

No

Supply (Dual or Single)

Sprinkler %

Smoke detection?

Yes

No

Coverage %

Hardwired or battery?

Monitored by a third party?

Yes

No

Local Only?

Yes

No

Theft & Security

Do you have any of these on site?

CCTV

Security Patrols

Burlgary alarm (Local or monitored)

Window Security Grills

Burglar Alarms

Do you hold over 10,000 in cash on premises?

What sort of safe is used?

Do you use contracted money carriers?

Situtation Declared Values

Building

Contents

Stock

Removal of Debris

Sublimits

Section 1

Burglary (other than money)

Extra Cost of Reinstatement

Glass

Money

Unspecified/accidental damage

Propety in Open Air

Other

Section 2

Gross Profit

Rental Income

ACIOW

Payroll

100% x weeks

% x weeks

Other

Aggregated Schedule - Total Insured Value (TIV)

Section 1 - Material Loss or Damage

Buildings

Contents

Stock

Removal of Debris

Additional Extra Cost of Reinstatement

Section 2 - Consequential Loss

Gross Profit

Rental Income

Payroll

Claims Prep. Cost

Additional Extra Cost of Reinstatement

Indemnity Period

Combined Section 1 & 2 - Material Loss or Damage

Declaration

I declare that to the best of my/our knowledge and belief the answers given above, documents or papers submitted, represent the true position and that We have not withheld any information, material to this proposal.
I acknowledge that no cover is provided unless and until;

Ocean Underwriting advise in writing of the cover and terms which they can provide, and
this cover including the terms and conditions is then accepted by me, and
Ocean Underwriting are advised by me of acceptance of their cover and terms offered, and
Ocean Underwriting acknowledges to me that cover is provided.

Where answers in this proposal are not in my own handwriting, they have been checked by me and I agree that they are correct.
I have read and understood the Your Duty of Disclosure notice in this proposal form. I authorise Ocean Underwriting to give to, or obtain from other insurers or an insurance or credit reference bureau, any information relating to or which may impact on this insurance cover, and any other insurances held by Me and claims under those insurances.
I agree that this proposal and accompanying documents or papers shall form part of this proposal and are the basis of the insurance contract proposed.

Untitled(Required)

I have read and agree to the duty of disclosure requirements.

Declaration signature(s) on behalf of the applicants:

Signature(Required)

Print Name:(Required)

First Last

Phone Number(Required)

Date(Required)

DD slash MM slash YYYY

Your email address (to receive a copy of this proposal)(Required)

Δ

Coverholder_at_Lloyds

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Level 6, 60 Clarence Street
Sydney NSW 2000
hello@oceanunderwriting.com.au
(02) 9051 0708

Ocean Underwriting acknowledges the Gadigal people of the Eora Nation as the Traditional Custodians of the Country on which we conduct our business. We pay our respect to elders past and present and extend that respect to all Aboriginal and Torres Strait Islander peoples today.

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Pty Ltd ABN: 34 640 933 937
AFSL: 542842

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