Oz Prize | Equipment Insurance Quotation Request Form

Ozprize & Weather Insurance Specialists is a Corporate Authorised Representative of Insurance Advisernet Australia Pty Ltd. AFSL No. 240549

Corporate Authorised Representative No. 309116 Visit the Insurance Advisernet website

02 9785 3413

Equipment Insurance Quotation Request Form

Equipment Insurance

Quotation Request Form
(Film, Musical & Audio Visual)

Free Text

Application/Schedule

(Please complete for all joint insureds)

Name of Insured

Date of Birth :

Postal Address :

Telephone No :

E-Mail Address :*

Address where equipment is usually stored :

Please describe security at normal place of storage for Doors & Windows :*

Free Text

Period of Insurance:

From :

To :

1. Has any proposal or renewal for insurance ever been declined?

YES

2. Has any insurance policy been cancelled by any insurance company?

YES

3. Have you ever had special conditions or increased premium imposed?

YES

If the answer is YES to any of the above questions please give written explanation.

4. Have you suffered any losses in the past five (5) years (whether insured or not)?

YES

If YES please describe

5. Any Interested Parties? (e.g. Finance Companies) :

Free Text

List of Equipment

(Please email your list to us if insufficient space here)

Equipment

Brand

Model

Serial No.

Replacement Value

Equipment

Brand

Serial No.

Replacement Value

Equipment

Brand

Model

Serial No.

Replacement Value

Equipment

Brand

Model

Serial No.

Replacement Value

Equipment

Brand

Model

Serial No.

Replacement Value

Equipment

Brand

Model

Serial No.

Replacement Value

Equipment

Brand

Model

Serial No.

Replacement Value

Equipment

Brand

Model

Serial No.

Replacement Value

Free Text

I/We hereby agree that if we accept the quotation, this application and declaration shall be the basis of the contract between myself/ourselves and The Underwriting Insurance Company I/we have chosen. I/we also acknowledge having read and understood the important notices forming part of this site (please click to read your “ Duty of Disclosure ”)

Agree

I/We Agree