Business Insurance Application Form

Business Insurance Application Form
Just fill out this application form below.
Details of Applicant
Fill out the contact info below:
Material Damage
Property details.
Sums Insured
The extensions listed below have standard sub limits and standard excesses applicable. If you wish to select a different amount to the standard, please specify amount in the table below:
Construction type:
- Brick
- Wood
- Mixed
If built pre-1935, is it strengthened for earthquake?
- Yes
- No
Security And Safety
Please indicate which of the following apply to the premises.
Is it alarmed?
- Yes
- No
Is it monitored?
- Yes
- No
Are there fire extinguishers/fire protection equipment?
- Yes
- No
Are there single supply sprinklers?
- Yes
- No
Liability
If you are taking out liability insurance, complete the following “About the Business” section in all cases. Then complete only the sections for the cover you require: “Broadform Liability”, “Statutory Liability” and/or “employer’s Liability”.
About the businesses-
Does the Business store other people’s property?
- Yes
- No
Does the Business ever include the excavation of land?
- Yes
- No
Does the Business agree to obligations under any contract (including any agreement with others to indemnify or hold harmless) which are greater than those generally imposed by law?
- Yes
- No
Do you export your product?
- Yes
- No
Does your business have an ISo 9000 series approval?
- Yes
- No
Have the products been vetted by your legal advisors to conform to statutory, government or other regulations of the countries to which they are exported?
- Yes
- No
Have any circumstances in the last 5 years ever occurred which could result in a claim under this cover you are applying for?
- Yes
- No
Do you need, or have you ever applied for, a resource consent and/or certificate of compliance under the resource management Act?
- Yes
- No
Have you previously held Business insurance?
- Yes
- No
Have you had any accidents, claims or losses, whether or not the subject of an insurance claim, in the past 5 years?
- Yes
- No
Have you ever been refused insurance, refused to have insurance continued, or had special terms imposed on you by any insurer?
- Yes
- No
Does anyone (other than the Insured) have a financial interest in any property?
- Yes
- No
Have you ever been imprisoned for any criminal offence, or prosecution, other conviction for last 7 years?
- Yes
- No
Agreement
- All information given to NZI (whether oral or written) is correct.
- The terms of NZI’s policies are accepted.
- Any personal information held by other members of the insurance industry and Insurance Claims register Ltd may be disclosed to NZI.
- Anyone who assists me to complete this Application Form is acting as my agent only.
- I agree to above terms and condition.

Business Insurance Application Form

Details of Applicant

Material Damage

Sums Insured

Security And Safety

Liability

Your Company Name

A brief intro is always great. It's Helps people to identify your company.