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Your Name:
Your Phone No:
Your Email:
Brokerage Name:
Australian Financial Services Licence No:
Clients Name:
Business Address:
Annual Turnover:

Number of Members:
Current Insurer:
Expiry Date:    
Holding Broker:
   
 

Does the Personal Trainer offer any of the following activities:

Physiotherapy , Professional Nutritionist, Swimming Pool, Ball sports/Racquet Sports, Rock Climbing, Massage, Beautician,   Equipment Hire

 Yes NO

Please select the property cover you require:
Fire Yes NO

Please supply the following information about the premises:

Construction:

Security:

Deadlocks    Bars on Windows    Local Alarm        Monitored Alarm
Fire Prevention: Extinguishers Smoke Detectors Monitored Smoke Detectors Sprinkler System
Is cooking carried out on the premises? Yes No                             If Yes is a Deep Fryer Used : Yes  No
 
Building:

Contents including Stock
Other: 


Business Interruption Yes NO


Burglary Yes NO


Money Yes NO


Glass Yes NO


Broadform Liability / Errors & Omissions Extension Yes NO


Machinery Breakdown Yes NO


Electronic Equipment Yes NO


General Property Yes NO


Has the insured had any claims in the past 5 years that would be covered by the proposed insurance?   Yes NO


Is there any other information you would like to provide? Yes NO
Your Name:      
Date:     
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