Authorised Financial Services Provider - FSP NO: 20816
Plant All Risk Insurance Questionnaire
Fill in Application
A. Broker Details
Name of Broker
Contact Person
Tel Number
Fax Number
B. Insured Details
Name of Insured
Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Postal Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Tel Number
Business of Insured
VAT Number
C. Insurance History
Has there been any previous insurance?
Yes
No
If Yes, which company
Claims History
Plant to be Insured on the following
Agreed Value (AV)
Market Value (MV)
New Replacement Value (NRV)
Is Windscreen/Glass required?
Yes
No
Is On-site Public Liability cover required?
Yes
No
Is Road Risk Liability cover required?
Yes
No
Item 1
Item 1 Price
Item 2
Item 2 Price
Item 3
Item 3 Price
Item 4
Item 4 Price
Item 5
Item 5 Price
Item 6
Item 6 Price
Item 7
Item 7 Price
Item 8
Item 8 Price
Item 9
Item 9 Price
Item 10
Item 10 Price
Item 11
Item 11 Price
Item 12
Item 12 Price
D. Declaration
Form filled in By
Date
/
DD
/
MM
YYYY
Broker to mail to:
