JUA Underwriting Agency Pty Limited

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	JUA Online Quotation Form (All classes) Please submit this Form and we will have your terms back to you within 48 hours. Note: JUA Underwriting Agency Pty Ltd only deals with Australian-based registered insurance brokers as licensed by the Australian Securities and Investments Commission (ASIC). Accordingly, please submit a quotation ONLY if you are registered insurance broker. If you are NOT a registered insurance broker, please refer to your registered insurance broker or to your local directory to select a registered insurance broker.


	1. Insurance Broker

	Name of the Insurance Broking Firm:
	Address:
		State:	Postcode:
	Name of the Insurance Broker:
	Contact details:	Phone :
		Fax:
		Email:


	2. Insured's Details

Full Name/s:
T/as Name:
Risk Situation:		Mobile Phone:
Website address:		Business Phone
E-mail address:		Business Fax:
		:




	3. Business Details

Description of Business/Occupancy:
Years in Business:			Years in Industry:
Wok cooking:	Yes No		How often are Flues cleaned?
Any type of Deep Frying:	Yes No		Weekly Fornightly Monthly
Capacity:	litres		How often are Filters cleaned?
Thermo cut-off:	Yes No		Weekly Fornightly Monthly
Wood cutting:	Yes No		Quantity of flammables:	litres
Hot work:	Yes No		Cleaned under contract:	Yes No
Gross T/over:			Dust extraction system:	Yes No
Number of principals:			No smoking policy:	Yes No
Number of employees:			Wages:
Fees to contractors/subcontractors:
Services provided by contractors/subcontractors:




	4. Insurance & Loss Background

Full details of prior claims/uninsured losses, bankruptcy &/or criminal charges/convictions:

Previous Insurer:		Due date:	/ /
Renewal offered:	Yes No	Reason for decline:




	5. Building & Security Details

Wall construction:		Roof construction:
Floor construction:		No. of storeys:
Age:		Heritage listed:	Yes No
Occupancy to rear:		Occupancy to left:
Occupancy to right:		Hose reels & number:
Extinguishers & number:		Hydrants	Yes No
Fire Blanket & number:		Heat detectors:	Yes No
Smoke detectors:	Yes No	Sprinklers:	Yes No
On town water:	Yes No	Are all fire fighting appliances under a service contract:
			Yes No
If NOT on town water, full details of fire protection systems & water supply:

Alarm installed:	Yes No	Back to base:	Yes No
Monitored by security:	Yes No	Local sounder:	Yes No
D/locks on all doors:	Yes No	Bars on all windows:	Yes No
Key locks on windows:	Yes No	Security patrols:	Yes No
Additional Information:




	6. Fire & Specified Perils

Building:	$	Machinery/Plant:	$
Contents:	$	R.O.D.:	$
Stock:	$	Loss of Rent:	$
Other - must specify:




	7. Business Interruption

Gross Profit:	$	Indemnity Period:
Loss of Rent:	$	Wages:	$
I.C.O.W.:	$	Professional Fees:	$
Other - must specify:




	8. Burglary

Contents:	$	Liquor:	$
Mach/Plant:	$	Cigs/Tobacco:	$
Stock:	$	Damage:	$
Other - must specify:




	9. Money

Premises (B/Hrs):	$	In locked safe/s'room:	$
Premises (Non-B/Hrs):	$	Damage to safe:	$
In Transit:	$	Personal Custody:	$
Other - must specify




	10. Glass

Internal fixed glass:	Yes No	Signwriting - SI:	$
External fixed glass:	Yes No	Signs - SI:	$
Other - must specify:




	11. Liability

Public Liab.	$	Product Liab.	$
Property Owner:	$	Tenants Liab.	$
Type of Third Party Property in custody:		Required sum insured for Third Party Property in custody:	$




	12. General Property

Note: cover is limited to Fire, Burglary from locked premises only, & Accidental Damage from collision/overturning of conveying vehicle
Sum Insured:	$
Description of items to be insured:




	Submit your Request for a Quotation

	How do you want to send this form to JUA? Please select an option:
		OR	Instantly send your request for a Quotation to JUA via the internet now, and we will have your terms back to you within 48 hours. Please note that you can also Print your Quotation details in the next screen.
			Print your request for a Quotation details and fax to: (02) 9247 2411.