Quotation request form for Equipment Insurance (Film, Musical & Audio Visual) OzPrize & Weather Insurance Specialists Pty Limited 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: Period of Insurance: From: To: 1. Has any proposal or renewal for insurance ever been declined? YesNo 2. Has any insurance policy been cancelled by any insurance company? YesNo 3. Have you ever had special conditions or increased premium imposed? YesNo 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)? YesNo If YES please describe 5. Any Interested Parties? (e.g. Finance Companies) List of Equipment List of Equipment (Please email your list to us if insufficient space here) Brand Mode Serial No. Replacement Value 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 brochure.