Security Industry Insurance

Form Name

Form Version

Lead ID

CRM Layout ID

Lead Source

Lead Type

Existing or New Business

Business Type

Industry

Country

Application Sent

Application Received

First Name*

Last Name*

Phone*

Mobile*

E-mail*

Full Name of Insured (Company Name)*

Base of Operation*

Business Description*

Street Address*

State*

City*

Postcode*

Estimated figures for coming 12 months Actual figures for past 12 months

Estimated Turnover*

Actual Turnover*

Estimated Payroll*

Actual Payroll*

Estimated Subcontractor Payments*

Actual Subcontractor Payments*

Have you had any claims in the last 5 years?*

YesNo

Please provide full details of claims history*

Attach claims history on previous insurer's letterhead

Upload a File

Have you ever had insurance refused/declined/cancelled or special terms imposed?*

YesNo

Please provide full details of insurance refusals/cancellations or special terms*

Have you ever been convicted of fraud, arson, theft or any other criminal act?*

YesNo

Please provide full details of convictions*

Have you ever been declared bankrupt or filed for bankruptcy?*

YesNo

Please provide full bankruptcy details*

Current Insurer*

Proposed Start Date*

DayMonthYear

Limit of Liability Cover Required?*

Errors & Omissions Cover Required?*

Yes - $1,000,000No

Loss of Keys Cover Required?*

YesNo

Loss of Keys Cover Amount*

Excess Options*

$10,000 minimum required for Crowd Control

Cash in Transit Cover Required?*

YesNo

Cash in Transit Cover Amount*

Do you use Guard Dogs?*

YesNo

Do you use Firearms?*

YesNo

Please indicate the % of Annual Turnover as applicable to the types of work undertaken.

Mobile Patrols/Static Guarding

Alarm Response

Cash in Transit

Concierge

Body Guarding

Traffic Control

Debt Collector

Private Investigator

Alarm Monitoring

Security Consultant

Alarm Products Design/Alterations

Alarm Installation Non-Residential

Alarm Installation Residential

Crowd Control

Security Trainer

Airport Security

Duty of Disclosure Notice

Before you enter into an insurance contract, you have a duty to tell the insurer anything that you know, or could reasonably be expected to know, may affect their decision to insure you and on what terms.

You have this duty until they agree to insure you.

You have the same duty before you renew, extend, vary or reinstate an insurance contract.

You do not need to tell the insurer anything that:
   - reduces the risk they insure you for; or
   - is common knowledge; or
   - they know or should know as an insurer; or
   - they waive your duty to tell them about.

If you do not tell the insurer something
If you do not tell the insurer something you are required to, they may cancel your contract or reduce the amount they will pay you if you make a claim, or both.

If your failure to tell them is fraudulent, they may refuse to pay a claim and treat the contract as if it never existed.

I have read, understand and agree to the above Duty of Disclosure notice*

Yes

I have read, understand and agree to the Financial Services Guide*
A copy of this can be found at http://www.amsinsurance.com.au/downloads/AMS_FSG.pdf

Yes

I have read, understand and agree to the Privacy Policy*
A copy of this can be found at http://www.pscconnect.com.au/privacy/

Yes

Signature*

1. Your Details

2. Company Details

3. Claim History

4. Coverage Details

5. Acknowledgements