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Contact Name *

First Name

Last Name

Mobile Number *

Other Phone Number

Email Address *

Policy Commencement *

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Capacity *

Business Name (if applicable)

Business Type (if applicable)

Address of risk *

Address 1

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Products you would like us to quote on: *

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Public and Products Liability

Business Insurance (including glass, fire & other damage, business interruption, burglary, money)

Commercial Motor / Fleet Insurance

Professional Indemnity Insurance

Management Liability Insurance

Directors and Officers Liability Insurance

Marine Cargo / Transit Insurance

Contract Works / Construction Insurance

Commercial / Domestic Strata Insurance

Cyber Insurance

Farm / Livestock / Equine Insurance

Home and Contents Insurance

Private Motor Insurance

Landlords Insurance

Boat / Pleasure Craft Insurance

Other

Cover Details

Estimated annual turnover (if applicable)

Number of employees (if applicable)

Public Liability Cover Required (if applicable)

Estimated value of building (if applicable)

Estimated value of contents/stock (if applicable)

Estimated weekly rental (if applicable)

Additional information / comments

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A member of our team will be in touch within 2 business days.

General Advice Warning – the information above is intended as a guide only and should not be relied upon without consulting your relevant insurance policy wording and conditions or conversely seeking professional advice from either your insurance broker or insurer regarding a claim or potential loss.

Acurancy Insurance Services

451 Pitt Street,

Sydney, NSW 2000,

Australia

1300 322 511 admingi@acurancy.com.au

Hours

Mon 08:30 to 17:30

Tue 08:30 to 17:30

Wed 08:30 to 17:30

Thu 08:30 to 17:30

Fri 08:30 to 17:30

Acurancy Insurance Services Pty Ltd - ABN 60 085 244 435 CAR No. 277043 | Acurancy Insurance Services (Melbourne) Pty Ltd - ABN 96 607 846 515 CAR No. 1251089 | Acurancy Insurance Services (WA) - ABN 57 626 808 008 CAR No. 1266398
are Corporate Authorised Representatives of Community Broker Network | AFSL 233750