Please complete the below form.
This application is submitted on the basis that:
- There have been no claims made to the knowledge of the Applicant against the Applicant, any business predecessors, or any of the present or former partners and/or officers within the last 5 years
- The Applicant is not aware of any fact or circumstance which could give rise to a claim against the Applicant or any business predecessors, or any of the present or former partners and/or officers
- To the knowledge of any Partner, Executive Officers, Director or Employee, no insurance company declined or terminated the insurance for the Applicant, any business predecessors or any present or former partners an/or officers
- The Applicant has not been refused a business insurance policy
By submitting this business insurance application you declare that the above statements and particulars are true and that you have not suppressed or misstated any material facts, and that you agree that this declaration shall be the basis of any binder or contract of business insurance with the Insurer. The limits and deductibles as stated in the said binder or contract of business insurance shall govern.
It is understood and agreed that the completion of this application does not bind the Insurer to the issue of the business insurance nor the Applicant to the purchase of the business insurance.
It is further understood and agreed that if, following submission of this application to the Insurer and prior to the date requested for coverage to be effective, the Applicant becomes aware of any information which has a bearing with regards to this application, the Insurer shall be immediately notified in writing of such information.
Note: The policy does not cover any claim or circumstance stated above or any act, error, omission or circumstance which could give rise to a claim, of which the Applicant has knowledge prior to the inception of the policy.