Business Insurance Form
Your Details
Full name: (incl Title)
*
Contact telephone number:
*
Email address:
*
Business Details
Name of business: (legal entity)
*
Business address:
*
Postcode:
*
Business type:
*
Estimated turnover:
*
Insurance Requirements
Buildings sum insured
Contents sum insured
Stock sum insured
Gross Profit sum insured
Public Liability cover required
Yes
No
Glass cover required
Yes
No
Money cover required
Yes
No
Machinery or Electronic Breakdown required
Yes
No
General Property cover required
Yes
No
Any other specific cover required. Please detail
Please provide full details of any claims made and/or losses suffered under previous Business Insurance during the past 5 years (whether or not a claim was made):
*
If none, please state
Please use this box to provide any further information that may be relevant to your Business Insurance policy :
Current Business Insurance provider:
*
If none, please state
Current Business Insurance premium:
*
If none, please state
Renewal date of existing insurance/date cover to start (as applicable):
*
NB: Cover is not in force until agreed upon by the company
Contacting You
Are you an existing Bruce Insurance customer?
*
yes
no
Preferred contact method:
*
Please select
Telephone
Email
Letter
Preferred contact time:
Please select
No preference
08:00-10:00
10:00-12:00
12:00-14:00
14:00-16:00
16:00-18:00
How did you hear about us?
*
Please select
Google search
Referred by friend
Referred by another business
Referred by another website
Search engine
Advertising
Bruce Insurance is a trading name of Bourchier Nominees Pty Ltd. We would like to contact you from time to time about products and services (or with news, offers and promotions) that we feel may be of interest to you. By providing us with your contact details, you consent to being contacted by these methods for these purposes.
Please tick the box if you prefer to
not
to receive marketing communications from us by post or telephone.
Please tick the box if you prefer to
not
receive marketing communications from us by email, text messaging or other electronic means.