Saturday, 19 May 2012
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Entertainment Equipment Insurance Proposal
  1. Please click here for important information on The Entertainment Equipment Insurance Proposal
  2. Where did you hear about Action Entertainment Insurance?
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  3. Insured name(*)
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  4. ABN #
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  5. Contact Person(*)
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  6. Postal Address(*)
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  7. Suburb(*)
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  8. State(*)
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  9. Post Code(*)
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  10. Phone number(*)
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  11. Fax number
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  12. Email address(*)
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  13.  
  1. Where do you usually store the equipment?(*)
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  2. Period of Insurance:

  3. From Date:
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  4. To Date (4.00PM):
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  5. Have you suffered any losses of equipment including theft, fire or damage (whether insured or not) in the last 5 years?(*)
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  6. If yes, please provide details
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  7. Have you previously been refused insurance or have had your insurance cancelled by an Insurer or have had special conditions, increased premiums or increased excesses imposed on any policy of insurance by an Insurer?
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  8. If yes, please provide details
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  9. Which type of cover do you required? (Please Tick)(*)


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  10. Premises Only-Address (if applicable)
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  11. Please advise names of interested parties (eg. finance companies etc)?
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  12. SCHEDULE OF ITEMS TO INSURE (please attach a schedule if insufficient space)

    NOTE THAT ONLY ITEMS APPEARRING ON THE SCHEDULE ARE COVERED UNDER THE POLICY

  13. Item 1 (Description - Make, Model, Serial No):
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  14. Item 1 Sum Insured
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  15. Item 2 (Description - Make, Model, Serial No):
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  16. Item 2 Sum Insured
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  17. Item 3 (Description - Make, Model, Serial No):
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  18. Item 3 Sum Insured
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  19. Item 4 (Description - Make, Model, Serial No):
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  20. Item 4 Sum Insured
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  21. Item 5 (Description - Make, Model, Serial No):
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  22. Item 5 Sum Insured
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  23. Item 6 (Description - Make, Model, Serial No):
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  24. Item 6 Sum Insured
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  25. Item 7 (Description - Make, Model, Serial No):
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  26. Item 7 Sum Insured
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  27. Item 8 (Description - Make, Model, Serial No):
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  28. Item 8 Sum Insured
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  29. Limit for miscellaneous items (leads, stands, pedals etc.)
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  30. Limit for hired or borrowed equipment
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  31. TOTAL(*)
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  32. Extra Schedule
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  33. Addional Info:
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  34. Declaration I/We hereby agree that this proposal & declaration shall be the basis of the contract between myself/ourselves & the Underwriting Insurance Company I/We have chosen. I/We also acknowledge having read & understood the Important Notices forming part of this application. In submitting this form, I acknowledge that I may receive documentation from Action Insurance Brokers P/L by email. I further agree that Action Insurance Brokers P/L may from time to time send me important information about new insurance products and services.

  35. I/We agree:(*)
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  36. Anti-Spam
    Anti-Spam
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  37. Submit