United Insurance Group
Business Pack Insurance
New Business Quote Request Form
1. Details
From Broker Message Ref. Date Created
United Insurance Group SB56069350 23/04/2024
To
Brief Description
Remarks
Remarks History
Attachments
2. Broker Contact
First Name Last Name Phone Number Fax Number
David Cheng 1300 542 573
Email Address Mobile Number
[Link]@[Link]
3. Client Details
Broker Client Code Broker Client Name
125100 V Concrete Built Pty Ltd
4. Period of Insurance
Start Date End Date Effective Date
1/05/2024 1/05/2025 1/05/2024
5. Applicant Details
5.1. Insured
Insured Name
V Concrete Built Pty Ltd
Trading Name
What is your web site URL?
What is your Input Tax Credit? 100
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What is your ABN? 32 612 301 578
Are you exempt from stamp duty? Yes X No If Yes, specify number:
Address Line 1
69 Power Road
Address Line 2
Suburb BAYSWATER State VIC Post Code 3153
5.2. Duty of Disclosure
Have you or any partner(s) or director(s) of the business:
(1
Ever had an insurance policy cancelled, declined or terms imposed? Yes X No
)
Date Description
(2
Ever been declared bankrupt? Yes X No
)
Date Description
(3 Ever been involved in a company or business which became insolvent or subject Yes X No
) to any form of insolvency or voluntary administration (e.g. liquidation or
receivership)?
Date Description
(4 Been convicted of any criminal offence within the past 5 years (other than minor Yes X No
) traffic convictions)?
Date Description
(5
Been liable for any civil offence or pecuniary penalty (exceeding $5,000)? Yes X No
)
Date Description
(6
Any other matters you should disclose? Yes X No
)
Date Description
5.3. Claims Experience
Any claims in the last 3 years under the sections to be insured? Yes X No
Claim # 1
Sections
Business Property Business Interruption
Theft Money
Machinery Breakdown Electronic Equipment
Public and Products Liability Glass
General Property Employee Dishonesty
Goods In Transit Tax Audit
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Management Liability
Date Of Loss Incurred
Description
Preventative/Corrective action details
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6. Situation Details
Situation: 69 Power Road BAYSWATER VIC 3153 (Principal)
6.1. Sections required for situation
Please select the sections required for this situation
X Business Property Business Interruption
Theft Money
Machinery Breakdown Electronic Equipment
X Public and Products Liability X Glass
X General Property Employee Dishonesty
Goods In Transit Tax Audit
Management Liability
6.2. Business Details
Business
Property Owner - Factory/Industrial
Describe Business if different from above
Estimated turnover for the next twelve months 0
6.3. Situation Details
Address Line 1
69 Power Road
Address Line 2
Suburb BAYSWATER State VIC Post Code 3153
Tenant Business
Tenant Business Boats Dealing
Tenant Business # 2 Commercial Building Construction - No Excavation
Tenant Business # 3
Construction
Year built (yyyy)
Year last rewired (yyyy)
How much Expanded Polystyrene (EPS) does the premises contain (e.g. Foam insulation)?
0%
Building Details
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Floors
X Concrete Iron / Steel
Brick Wood
Other/Mixed(Non Combustible) Other/Mixed (Full/Partial Combustible)
Tile
Walls
Concrete / Stone Concrete Tilt Slab
Iron/Steel/Aluminium on steel Iron/Steel/Aluminium on wood
Brick Masonry
Expanded Polystyrene (EPS) Wood
Mixed < 75% Brick/Concrete/Iron on steel X Mixed > 75% Brick/Concrete/Iron on steel
Glass Metal
Polystyrene Other
Roof
Concrete Masonry
Tiles / Slate Asbestos
Fibro X Iron/Steel/Aluminium on steel
Iron/Steel/Aluminium on wood Expanded Polystyrene (EPS)
Wood Polystyrene
Glass Other/Mixed (Non Combustible)
Other/Mixed (Full/Partial Combustible)
Fire Protection
Fire Protection Provided
None X Fire Extinguishers
Hose Reels Sprinklers
Smoke Detectors - Monitored X Smoke Detectors - Non Monitored
Heat Detectors Fire alarm
Monitored base alarm Fire Blankets
Sprinkler Type
100% Coverage Yes No
Water Supply Dual Single
Conforms to Australian Standards Yes No
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Security
Security Protection Provided
None Bars on windows
X Deadlocks on doors Protection of Display Windows
Electronic key pad/swipe card access X Security fencing
X Locks on all external windows without bars X CCTV system installed
Bollards infront of glazing/display windows/roller shutters X External Lighting
Local alarm Roller Shutters
Watchman patrols Monitored base alarm
If applicable, please specify the type of monitored alarm:
Class 2 e.g. Digital Dialler + GSM Cellular phone back-
Class 2 e.g. Digital Dialler
up polled daily
Class 4 + 5 e.g. Direct Line or Multi-path Ethernet
Class 3 e.g. Multi-path GPRS polled < 120 sec
/GPRS polled < 60 sec
6.4. Other Situation Details
Where are the premises located?
Wholly within a shopping centre (No external openings to
Main or Suburban street
outside centre)
Within a shopping centre (With external openings) X Within an Industrial Complex
Within an Office Block (incl Ground or 1st floor) Within an Office Block (2nd floor or above)
Outside Metropolitan, regional or town boundaries Shipping Container
Market Other
Is premises connected to town water?
X Yes No
Type Of Fire Brigade
X Professional Manned 24 hours Professional Manned part time
Own on site staff fire brigade Manned 24 hours Own on site staff brigade Manned part time
Rural or country volunteer brigade Other
Store Flammable Goods?
Yes X No
If Yes
What quantity 0
Store substances in accordance with Australian Standards and local/ state government regulations?
Yes No
If Yes, are goods stored in approved cabinets/bunded storage facilities?
Yes No
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6.5. Interested Parties
Do you wish to note any interested parties?
Yes X No
If Yes, Interested Party # 1
Sections
Business Property Theft
Money Machinery Breakdown
Electronic Equipment Public and Products Liability
Glass General Property
Employee Dishonesty Goods In Transit
Tax Audit Management Liability
Name
Nature of Interest
1st Mortgagee 2nd Mortgagee 3rd Mortgagee
Local Government Authority Hire Purchase Landlord
Lease Premium Funder Principal
Other
Address Line 1
Address Line 2
Suburb State Post Code
7. Business Property
7.1. Business Property Information
Is your premises more than 50% vacant? Yes X No
Is the building heritage or national trust listed? Yes X No
Specify storage height?
Less than 3.5m 3.5m - 4m
X 4m - 6m Greater than 6m
Does your business involve plastics &/or fibreglass
Yes X No
moulding/extrusion?
Is there a no smoking policy in force on the premises? Yes No
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Are fixed dust / fume extractors fitted to all machinery? Yes No
Are the dust extraction units emptied and cleaned on a regular
Yes No
basis?
Is any woodworking carried out at the premises? Yes X No
If Yes, are fixed dust extractors fitted to all woodworking
Yes No
machinery?
If Yes, are the dust extraction units emptied and cleaned on a
Yes No
regular basis?
How often are the dust extraction units cleaned?
Weekly Fortnightly Greater
Is there a no smoking policy in force on the premises? Yes No
Do any of the tenants have bulk storage (more than 15% of floor
X Yes No
space)?
7.2. Sum Insured
Do you require Strata title mortgagee(s) interest cover only? Yes X No
Building(s) 2,000,000 X Replacement Indemnity
Contents 1,500,000 X Replacement Indemnity
Stock 0
Specified Item Sum Insured
Category
Antique Customer vehicles
Container contents Customer goods
Floating stock Floating stock and/or contents
Stock of caravans Stock of petrol
Stock of watercraft Work of art
Other
Total Sum Insured 3,500,000
Limit of Liability 4,200,000
7.3. Additional Cover
Extra Cost of Reinstatement X Wording Coverage Other Amount
If Other Amount, specify amount 0
Removal of Debris X Wording Coverage Other Amount
If Other Amount, specify amount 0
Rewriting of Records X Wording Coverage Other Amount
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If Other Amount, specify amount 0
Playing Surfaces X Wording Coverage Other Amount
If Other Amount, specify amount 0
Flood Yes X No
7.4. Deductible
Business Property
$ 100 X $ 250 $ 500 $ 750
$ 1,000 $ 2,000 $ 5,000 $ 7,500
7.5. Other Underwriting Information
Do you wish to add any printable notes? Yes X No
If Yes, Printable Notes
8. Public and Products Liability
8.1. Limits of Liability
Limit of Liability - Public & Products Liability
$ 5,000,000 $ 10,000,000 $ 15,000,000 $ 20,000,000 Other
If Other Amount, specify amount 0
8.2. Additional Cover
Property in Physical & Legal Control - Limit X Wording Coverage Other Amount
If Other Amount, specify amount 0
USA / Canada Exports Yes X No
If Yes, Product Turnover
8.3. Deductible
Property Damage Excess
$ 100 $ 250 X $ 500 $ 750 $ 1,000
$ 2,000 $ 5,000 $ 7,500 $ 10,000
8.4. Details of the Business
Property Owner Liability only? X Yes No
8.5. Contractors and Subcontractors
Do you engage contractors and/or subcontractors in your
Yes X No
business?
If Yes:
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Do you ensure that contractors and/or subcontractors have their
own liability and where necessary, Workers Compensation Yes No
insurance?
Estimate of the amount to be paid to contractors and subcontractors in the next 12 months:
Labour only $
Labour and plant $
Labour, plant and materials $
What type(s) of work do contractors and/or subcontractors perform for you?
8.6. Labour Hire
Do you engage labour hire or hired in labour in your business? Yes X No
Estimate the amount to be paid to labour hire firms in the next $
12 months
What type(s) of work do staff from labour hire firms perform for you?
8.7. Hazardous Activities and Substances
Do you, or do you intend to use, store or handle hazardous
Yes X No
substances?
Describe the hazardous materials used and/or the hazardous waste produced
Do you discharge waste or hazardous material into the
Yes X No
atmosphere, sewer or elsewhere?
If Yes, please provide details
Do you perform "hot work" away from own premises that involves
Yes X No
the use of cutting, welding, grinding or soldering equipment?
If Yes, describe the activities performed.
8.8. Hire Out Equipment or Staff
Do you hire out equipment and/or staff? Yes X No
If Yes:
Is there a Hire Agreement with a disclaimer or legal waiver in
Yes No
place that the hirer signs before hiring?
Is all equipment checked and maintained after each hire? Yes No
Equipment hired out Turnover
Does the business hire out any of the following: Yes No
-medical or surgical equipment
-watercraft
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-jumping castles
-elevated work platforms/scaffolding
-motorised cutting/sawing equipment
-self-propelled vehicles without an operator
Annual payment derived from activity by hired staff ($)
Details required on work performed from this activity by hired staff
8.9. Other Details
What is the total number of car parking spaces?
0 X 1-10 11-20 21-30 31-50 51-100 100+
In the last 6 years or in the future, do you intend to undertake
business or export to any of the following countries - Belarus,
Burma (Myanmar), Cote d'Ivoire, Cuba, The Democratic Republic Yes X No
of the Congo, Iran, Iraq, Liberia, North Korea, Sudan, Syria or
Zimbabwe?
If Yes, please provide details
Do you, or do you intend to export goods? Yes X No
If Yes, please provide details
Do you intend to engage in any overseas activities in the next 12
Yes X No
months?
Please provide further details of overseas activities including turnover
In which state/s does the business generate turnover? (Enter $ amount)
ACT 0
NSW 0
VIC 0
QLD 0
SA 0
WA 0
TAS 0
NT 0
8.10. Optional Extensions
Consumer Protection Liability cover
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X Not Insured Victorian Plumbers Queensland Electricians
Licensed Name
Licence Number
Licensed Name # 1
Licence Number
8.11. Other Underwriting Information
Do you wish to add any printable notes? Yes X No
If Yes, Printable Notes
9. Glass
9.1. Cover
External Glass X Yes No
Glass Exposure
Minor (excludes showroom) Medium or showroom less than 50sqm
Large
Internal Glass X Yes No
Do you wish to add any specified glass items? Yes X No
If Yes, Description
Floors Occupied
Ground floor Ground floor plus one or more floors
9.2. Additional Benefit
Signs X Wording Coverage Other Amount
If Other Amount, specify amount 0
9.3. Extra Covers
Costs
X Wording Cover Other
Sum Insured
Destruction of Stock or Contents
X Wording Cover Other
Sum Insured
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9.4. Deductible
Glass
$ 100 X $ 250 $ 500 $ 750 $ 1,000 $ 2,000
9.5. Other Underwriting Information
Do you wish to add any printable notes? Yes X No
If Yes, Printable Notes
10. General Property
10.1. Unspecified Business Items Sum Insured
Unspecified Business items 0
Specified Item #1
Description
Type
Laptops/Portable elect. equip(excl mob phones/PDAs) Mobile phones & PDAs
Tools of Trade excl left on building site overnight Tools of Trade when left on building site overnight
Stock in Trade of Tradesman Household Goods in Storage
Traveller Samples Other Specified Items
Sum Insured 0
10.2. Deductible
General Property
$ 100 X $ 250 $ 500 $ 1,000 $ 2,000
Goods in Transit Excess (CGU only)
$ 250 $ 400 $ 500 $ 1,000 $ 2,500 $ 5,000 $ 10,000
10.3. Cover Extensions
Worldwide Cover X Yes No
Goods in Transit Yes X No
Estimated Annual Sendings
Limit any one Load
10.4. Cover Limitations
Fire, theft, collision and other expressed perils Yes X No
10.5. Other Underwriting Information
Do you wish to add any printable notes? Yes X No
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If Yes, Printable Notes
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