Drycleaners Quote Form

Details of Party to be Insured

Entity Name *Company Name eg. Sampletown Drycleaners Pty Ltd

Business Name *Trading Name - eg. Sampletown Drycleaners

Contact Email *

Business Phone Number *

Has your business postal address changed within the last 12 months? *

YesNo

What is your new postal address? *

ABN *

Number of Staff *

Annual Gross Revenue *

Current Insurer *

Current policy expiry date

Are you a Drycleaning Institute of Australia (DIA) member? *

YesNo

Who were you referred by? *

Not referredBrokerDIAOther

If you selected other, please specify here

Business Package Insurance

How many locations do you need to insure?Note - If you own multiple properties across different locations, please fill out the details for each property below.

Property Details

Address of Property to be Insured *

Is this a Plant or Dry Store? *

Landlords entity name detailed within lease to be listed as an interested party (if applicable) *

Approx. Year Built *

Are the walls insulated with expanded polystyrene (foam type material) to your knowledge? *

NoYes

No. of Building Levels / Storeys *

Flooring *

Concrete SlabBricksWooden Floor Foundation

Location *

Street facingWithin a shopping centreWithin an industrial complex

What are the business activities of the adjoining tenancies? *

Please provide a brief description of any chemicals and flammables stored on site (including volumes and storage arrangements) *

Nominated Insured Values

Replacement value of contents / stock *

Building replacement value If applicable - property owner only

Theft of Contents *

Machinery Breakdown (optional cover) *

YesNo

Internal / External glass cover *

No Yes

Usually required as part of lease

Liability - Turnover and Staff *

$10 million$20 million

Location 2: Property Details

Address of Property to be Insured

Is this a Plant or Dry Store?

Landlords entity name detailed within lease to be listed as an interested party (if applicable)

Approx. Year Built

Are the walls insulated with expanded polystyrene (foam type material) to your knowledge?

NoYes

No. of Building Levels / Storeys

Flooring

Concrete SlabBricksWooden Floor Foundation

Location

Street facingWithin a shopping centreWithin an industrial complex

What are the business activities of the adjoining tenancies?

Please provide a brief description of any chemicals and flammables stored on site (including volumes and storage arrangements)

Location 2: Nominated Insured Values

Replacement value of contents / stock

Building replacement value If applicable - property owner only

Theft of Contents

Liability - Turnover and Staff

$10 million$20 million

Location 3: Property Details

Address of Property to be Insured

Is this a Plant or Dry Store

Landlords entity name detailed within lease to be listed as an interested party (if applicable)

Approx. Year Built

Are the walls insulated with expanded polystyrene (foam type material) to your knowledge?

NoYes

No. of Building Levels / Storeys

Flooring

Concrete SlabBricksWooden Floor Foundation

Location

Street facingWithin a shopping centreWithin an industrial complex

What are the business activities of the adjoining tenancies?

Please provide a brief description of any chemicals and flammables stored on site (including volumes and storage arrangements)

Location 3: Nominated Insured Values

Replacement value of contents / stock

Building replacement value If applicable - property owner only

Theft of Contents

Liability - Turnover and Staff

$10 million$20 million

Location 4: Property Details

Address of Property to be Insured

Is this a Plant or Dry Store?

Landlords entity name detailed within lease to be listed as an interested party (if applicable)

Approx. Year Built

Are the walls insulated with expanded polystyrene (foam type material) to your knowledge?

NoYes

No. of Building Levels / Storeys

Flooring

Concrete SlabBricksWooden Floor Foundation

Location

Street facingWithin a shopping centreWithin an industrial complex

What are the business activities of the adjoining tenancies?

Please provide a brief description of any chemicals and flammables stored on site (including volumes and storage arrangements)

Location 4: Nominated Insured Values

Replacement value of contents / stock

Building replacement value If applicable - property owner only

Theft of Contents

Liability - Turnover and Staff

$10 million$20 million

Location 5: Property Details

Address of Property to be Insured

Is this a Plant or Dry Store?

Landlords entity name detailed within lease to be listed as an interested party (if applicable)

Approx. Year Built

Are the walls insulated with expanded polystyrene (foam type material) to your knowledge?

NoYes

No. of Building Levels / Storeys

Flooring

Concrete SlabBricksWooden Floor Foundation

Location

Street facingWithin a shopping centreWithin an industrial complex

What are the business activities of the adjoining tenancies?

Please provide a brief description of any chemicals and flammables stored on site (including volumes and storage arrangements)

Location 5: Nominated Insured Values

Replacement value of contents / stock

Building replacement value If applicable - property owner only

Theft of Contents

Liability - Turnover and Staff

$10 million$20 million

Claims Details

Have you made any property claims in the last 3 years? *

Yes (can be multiple)No

What occurred?

Date of Incident

Amount paid by insurer

Risk Management Requirements

Please check which of the below risk requirements your business satisfies:

Thermography Survey Report – (within 60days of inception, then Biannual).Maintenance Contract on Machinery in line with OEM requirements. The original equipment manufacturer (OEM) will outline minimum maintenance requirements to keep the machinery in good working order. Service contractors will be aware of these, or they will be able to obtain from these from the EOM’s.Lint filters cleared dailyAny flammable or solvent liquids > 25ltrs to be stored in dedicated flammable liquid cabinetTrade waste to be placed in metal bins with closable lidsNo waste to be stored in or around the buildingNo smoking in or around the building

Other Cover

Are you interested in receiving quotations for any additional covers? *

Yes, Cyber InsuranceYes, Motor Vehicle InsuranceYes, Home and Contents InsuranceYes, OtherNo thank you, we are not interested in receiving quotes for any additional covers.

Additional Comments

Important Notices

Your Duty of Disclosure

This policy is subject to The Insurance Contracts Act 1984. Under that Act You have a Duty of Disclosure. This means:

1. When You ask for cover, You must tell Us all that You know about the risk that You want covered which may affect Our decision:

To offer You cover, and
The terms and the cost of such cover.

2. If You ask for the cover to be renewed, extended, altered or reinstated You must tell Us:

If there have been any changes in what is covered, and
Of all things that may increase the chances of a claim.

What You Don’t Have to Tell Us

You do not have to tell Us of anything;

That reduces the chances of a claim. But, if You do, it may let Us offer You better terms.
That is common knowledge.
That we should know as a normal part of Our business.
If We waive Your Duty of Disclosure.

Non-Disclosure

If You don’t tell Us something that You know which may affect Our decision to offer You cover or the terms of that cover We may be allowed to:

Reduce the amount that We have to pay for a claim. This may mean that We would pay You nothing.
Cancel this policy. We may even be allowed to cancel this policy from the date that the cover started if You lie to Us or deliberately keep information from Us or mislead Us.

By completing this Proposal form You declare that:

You have read the above Important Notices
You understand and have complied with Your Duty of Disclosure.
The property that You want covered is in good condition.
All the information You have given in this form is correct as at the submission date
You are authorised to complete this information on behalf of the insured.

Completed by (First Name) *

Completed By (Last Name) *

Position (Job Title) *

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