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PO BOX 581 NORTH RYDE
BC 1670
Suite 5 Building 1 Pymble Corporate Centre
20 Bridge Street Pymble NSW 2073
Tel (02) 8873 3300
Fax (02) 8873 3399
Email info@custodianua.com.au
AFSL 301970
ABN 17 116 860 103
Quotation/Business
BUSINESS INSURANCE QUOTATION REQUEST
Broker Firm &
Contact Name
Contact Details
Date
Subject
Please provide your quotation based on the following
Insured
Address Of Risk
Occupation
Years In
Business
No Of
Employees
Wages
$
Turnover
$
Construction
Walls
Floors – Ground
Floors – Upper
Roof
Age Of Building
No Of Stories
Security
Back To Base Alarm
Local Alarm
Windows - Type Of Locks
Doors - Type Of Locks
Bars & / Or Grills
Other – please specify
Fire Protection
Sprinklers
Hose Reels
Extinguishers
Other – Please Specify
Services
Switchboards – Open Or Closed
Wiring – Last Rewired
Plumbing – Last Replumbed
Details Of Machinery
ie Number Of Machines
Holding Broker
Yes No
Current Underwriter
Expiry Date
Claims/Conviction Details
Last 5 Years