REQUEST A QUOTE Full Name *Full Address *Company/ Business Name (if any)Contact Number *Email *No. of Years in Current Business123455+Estimated Annual Turnover For The BusinessTotal Number Of Employees (Including Partners And Directors)Current Insurer (If Any)Details Of The Plant, Equipment, Machinery (Year, Make, Model)Sum Insured (Value)Is The Item RegisteredYesNoPlease Select Your Primary Business Activities/OccupationConstruction & Civil EngineeringEarthmoving & ExcavationAgriculture / Farming / HarvestingMining ActivitiesCrane OperationsDrilling & Boring OperationsLogging & ForestryTrenching/ Pipe LayingRoad Construction/MaintenanceBuilders & TradesmenDemolition WorkHire & RentalTransport OperatorOther (Please Specify)Please Select The Coverage Section/S Required From The Following (Refer Combined Package Section For Details Of The Coverage Offered Under Each Section)Material Damage - Comprehensive Cover for Plant, Equipment and MachineryPublic &Products (Broadform) LiabilityRoad Risk Liability – Third Party Property Damage Liability (For Registered Units)Hired In Plant/Equipment Insurance - Owned By Third PartyFinancial Protection/ Business Interruption (Consequential Loss)Personal Accident & Sickness Insurance – For Plant OperatorsBreakdown CoverHave You (The Insured) Or Any Of Your Directors Ever Had Any Insurance Declined Or Cancelled By An Insurer Or Had Any Special Conditions Imposed? *Please select an optionYesNoHave You (The Insured) Or Any Of Your Directors Ever Been Declared Bankrupt In Last 10 Years? *Please select an optionYesNoHave You (The Insured) Or Any Of Your Directors Had Any Criminal Convictions In The Last 10 Years? *Please select an optionYesNoHave You (The Insured) Suffered Losses Or Claims (Both Insured And Uninsured) In Relation To Contractor’s Plant, Mobile Machinery, Motor Machinery, Motor Vehicle, Public/Products Liability Insurance During The Last 5 Years?YesNoAre Any Of Your Machines Used Or Expected To Be Used For Dry Hire Activities (Hired Out Without Your Operator)?YesNoGeneral QuestionsHas the insured, or any director or officers been declared bankrupt or insolvent in last 10 years?YesNoHas the insured, or any director or officers been convicted of a criminal offence in last 10 years?YesNoHas the insured, or any director or officers had an insurance policy cancelled, declined or terms imposed?YesNoHad any of the driver/owners ever been convicted for driving under the influence of alcohol or drugs?YesNoHave any of the driver/owners had their license suspended or cancelled in last 5 years?YesNoHave any of the driver/owners had any motor claims or accidents in last 5 years?YesNoHave any of the driver/owners been convicted of any traffic offences in last 5 years?YesNoBy filling out this form, you confirm that the information you provide is accurate and agree to the Terms & Conditions and Privacy Policy *I AgreeRequest Quote
