Ezy Mart Application Form - A requirement of the program is that you have a minimum.
1. Select from Ezy Mart Packages
*
Level 1: Approx 30 to 50 Squares
Level 2: Stores between 50 to 80 Squares
Level 3: Stores between 80 to 120 Squares
Level 4: Stores greater than 120 Squares
2. Sub-limits Level 1
2. Sub Limits Level 1 - Approx 30 to 50 Squares
Fire
Fire : All Contents (Standard)
Please Select
Lvl 1: $30,000
Lvl 2: $80,000
Lvl 3: $120,000
Lvl 4: $150,000
Fire : All Contents - Request for Higher Limit
Fire: Stock (Standard)
Please Select
Lvl 1: $40,000
Lvl 2: $60,000
Lvl 3: $80,000
Lvl 4: $100,000
Fire: Stock - Request for Higher Limit
Business Interruption
Business Interruption: Gross Profit Basis (Standard)
Please Select
Lvl 1: $150,000 (Turnover 5,500/wk)
Lvl 2: $210,000 (Turnover 7,000/wk)
Lvl 3: $320,000 (Turnover 10,000/wk)
Lvl 4: $430,000 (Turnover 13,000/wk)
Business Interruption - Request for Higher Limit
Theft
Theft: Content & Stock (Tobacco separate)
Please Select
Lvl 1: $1,000
Lvl 2: $2,000
Lvl 3: $3,000
Lvl 4: $4,000
Theft: Content & Stock - Request for Higher Limit
Theft: Tobacco Only
Please Select
Lvl 1: $2,000
Lvl 2: $3,000
Lvl 3: $5,000
Lvl 4: $10,000
Tobacco - Request for Higher Limit
Money Section
Money Section (Blanket Cover)
Please Select
Lvl 1: $3,000
Lvl 2: $3,000
Lvl 3: $3,000
Lvl 4: $3,000
Inc. Bus. Tickets / Phone Cards
Money Section - Request for Higher Limit
2. Sub-limits Level 2
2. Sub Limits Level 2 - Stores between 50 to 80 Squares
Fire
Fire : All Contents (Standard)
Please Select
Lvl 1: $30,000
Lvl 2: $80,000
Lvl 3: $120,000
Lvl 4: $150,000
Fire : All Contents - Request for Higher Limit
Fire: Stock (Standard)
Please Select
Lvl 1: $40,000
Lvl 2: $60,000
Lvl 3: $80,000
Lvl 4: $100,000
Fire: Stock - Request for Higher Limit
Business Interruption
Business Interruption: Gross Profit Basis (Standard)
Please Select
Lvl 1: $150,000 (Turnover 5,500/wk)
Lvl 2: $210,000 (Turnover 7,000/wk)
Lvl 3: $320,000 (Turnover 10,000/wk)
Lvl 4: $430,000 (Turnover 13,000/wk)
Business Interruption - Request for Higher Limit
Theft
Theft: Content & Stock (Tobacco separate)
Please Select
Lvl 1: $1,000
Lvl 2: $2,000
Lvl 3: $3,000
Lvl 4: $4,000
Theft: Content & Stock - Request for Higher Limit
Theft: Tobacco Only
Please Select
Lvl 1: $2,000
Lvl 2: $3,000
Lvl 3: $5,000
Lvl 4: $10,000
Tobacco - Request for Higher Limit
Money Section
Money Section (Blanket Cover)
Please Select
Lvl 1: $3,000
Lvl 2: $3,000
Lvl 3: $3,000
Lvl 4: $3,000
Inc. Bus. Tickets / Phone Cards
Money Section - Request for Higher Limit
2. Sub-limits Level 3
2. Sub Limits Level 3 - Stores between 80 to 120 Squares
Fire
Fire : All Contents (Standard)
Please Select
Lvl 1: $30,000
Lvl 2: $80,000
Lvl 3: $120,000
Lvl 4: $150,000
Fire : All Contents - Request for Higher Limit
Fire: Stock (Standard)
Please Select
Lvl 1: $40,000
Lvl 2: $60,000
Lvl 3: $80,000
Lvl 4: $100,000
Fire: Stock - Request for Higher Limit
Business Interruption
Business Interruption: Gross Profit Basis (Standard)
Please Select
Lvl 1: $150,000 (Turnover 5,500/wk)
Lvl 2: $210,000 (Turnover 7,000/wk)
Lvl 3: $320,000 (Turnover 10,000/wk)
Lvl 4: $430,000 (Turnover 13,000/wk)
Business Interruption - Request for Higher Limit
Theft
Theft: Content & Stock (Tobacco separate)
Please Select
Lvl 1: $1,000
Lvl 2: $2,000
Lvl 3: $3,000
Lvl 4: $4,000
Theft: Content & Stock - Request for Higher Limit
Theft: Tobacco Only
Please Select
Lvl 1: $2,000
Lvl 2: $3,000
Lvl 3: $5,000
Lvl 4: $10,000
Tobacco - Request for Higher Limit
Money Section
Money Section (Blanket Cover)
Please Select
Lvl 1: $3,000
Lvl 2: $3,000
Lvl 3: $3,000
Lvl 4: $3,000
Inc. Bus. Tickets / Phone Cards
Money Section - Request for Higher Limit
2. Sub-limits Level 4
2. Sub Limits Level 4 - Stores greater than 120 Squares
Fire
Fire : All Contents (Standard)
Please Select
Lvl 1: $30,000
Lvl 2: $80,000
Lvl 3: $120,000
Lvl 4: $150,000
Fire : All Contents - Request for Higher Limit
Fire: Stock (Standard)
Please Select
Lvl 1: $40,000
Lvl 2: $60,000
Lvl 3: $80,000
Lvl 4: $100,000
Fire: Stock - Request for Higher Limit
Business Interruption
Business Interruption: Gross Profit Basis (Standard)
Please Select
Lvl 1: $150,000 (Turnover 5,500/wk)
Lvl 2: $210,000 (Turnover 7,000/wk)
Lvl 3: $320,000 (Turnover 10,000/wk)
Lvl 4: $430,000 (Turnover 13,000/wk)
Business Interruption - Request for Higher Limit
Theft
Theft: Content & Stock (Tobacco separate)
Please Select
Lvl 1: $1,000
Lvl 2: $2,000
Lvl 3: $3,000
Lvl 4: $4,000
Theft: Content & Stock - Request for Higher Limit
Theft: Tobacco Only
Please Select
Lvl 1: $2,000
Lvl 2: $3,000
Lvl 3: $5,000
Lvl 4: $10,000
Tobacco - Request for Higher Limit
Money Section
Money Section (Blanket Cover)
Please Select
Lvl 1: $3,000
Lvl 2: $3,000
Lvl 3: $3,000
Lvl 4: $3,000
Inc. Bus. Tickets / Phone Cards
Money Section - Request for Higher Limit
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Glass Replacement Value
The replacement value for breakage of glass per policy is "Replacement Value".
Limit under Benefits for Signs, Temporary Shutting, Safeguarding, etc. Limited to $7500.
Public Liability
Products Liability/Public Liability (in the aggregate) is $20,000,000.
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3. Your Information
Company / Entity Name
*
ABN
Contact Person / Director
*
Phone Number
Mobile Number
E-mail
*
Leasing Entity Name
*
ABN (Leasing Entity)
Contact Person (Leasing Entity)
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4. Your Store Information
4.1 Situation Details
Address
*
Suburb
*
State
*
Post Code
*
Age of Building/Year Built
Year renovated and rewired
Does your business contain any cool rooms?
Please Select
Yes
No
Date this was installed
Approximate percentage of floor space:
Building Type:
*
Office Building
Shopping Centre
Freestanding Commercial Building
Residential Building (100%)
Freestanding (Residential/Commercial)
Other
Where are the premises located?
*
Main or Suburban street
Within a shopping centre (with external openings)
Within an office block (incl Ground or 1st floor)
Outside Metropolitan, regional or town boundaries
Wholly within a shopping centre (No external openings to outside centre)
Mixed Commercial / Residential
100% Residential apartments
Other
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4.2 Building Details
Number of Stories
*
How many stories do you occupy?
*
Floors
*
Please Select
Concrete
Brick
Other/Mixed (Non-combustible)
Tile
Iron/Steel
Wood
Other/Mixed (Full/Partial Combustible)
Walls
*
Please Select
Concrete/Stone
Iron/Steel/Aluminum on steel
Brick
Expanded Polystyrene (EPS)
Mixed < 75% Brick/Concrete/Iron on steel
Glass
Polystyrene
Concrete Tilt Slab
Iron/Steel/Aluminum on wood
Masonry
Wood
Mixed > 75% Brick/Concrete/Iron on steel
Metal
Asbestos
Other
Roof
*
Please Select
Concrete
Tiles/Slate
Fibro
Iron/Steel/Aluminum on wood
Wood
Glass
Other/Mixed (Partial / full combustible)
Masonry
Asbestos
Iron/Steel/Aluminum on steel
Expanded Polystyrene (EPS)
Polystyrene
Other/Mixed (Non-combustible)
Fire Protection
*
Please Select
Fully Sprinklered - Dual Water Supply
Fully Sprinklered - Single Water Supply
Fully Sprinklered
Monitored Fire Alarm, Hose Reels & Extinguishers
Monitored Fire Alarm & Extinguishers
Extinguishers Only
No Protection
Liability and/or General Property cover(s) Only
Type of Alarm
*
Please Select
Back to Base - Secured Line
Back to Base - Unsecured Line
Monitored Alarm to Insured's Mobile Phone
Local Alarm
No Alarm
Liability and/or General Property cover(s) Only
Security: Security Protection(s) Provided - please tick all the security devices that apply:
*
None
Deadlocks on doors
Electronic key pad/swipe card access
Locks on all external windows without bars
Bollards in front of glazing/display windows/roller shutters
Local alarm
Monitored base alarm
Bars on windows
Protection of Display Windows
Security Fencing
CCTV system installed
External Lighting
Watchman patrols
If applicable, specify the type of monitored alarm:
Please Select
Class 2 e.g. Digital Dialler
Class 2 e.g. Digital Dialer + GSM cellular (back-up polled daily)
Class 3 e.g. Multi-path GPRS polled < 120 sec
Local to Insured's mobile phone
Local only - bells & sirens only
Other details: Is there an ATM on premises?
Please Select
Yes
No
Other building details
*
Yes
No
Is the building heritage listed?
1
2
Does the building have deadlocks on all external doors?
3
4
Does the building have keylocks and/or bars on all external windows?
5
6
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4.3 Interested Parties
Do you wish to note any interested parties?
*
Please Select
Yes
No
If Yes, interested party's name
*
If Yes, please select TYPE of Interested Party from selecting below
1st Mortgagee
2nd Mortgagee
3rd Mortgagee
Local Gov't Authority
Hire Purchase
Lease
Premium Funder
Principal
Other
Name
Address
Suburb
State
Post Code
Please advise which sections this Interested Party requires to be noted on: Risks
Business Property
Money
Electronic Equipment
Glass
Goods in Transit
Management Liability
Theft
Machinery Breakdown
Public & Products Liability General Property
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5. Past Claims
Have you had any claims within the last 5 years?
*
Yes
No
Have your total claims payments or losses exceeded $5,000 in the last years?
*
Yes
No
Year of Claim
Please Select
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Details of Loss
Glass
Fire
Water Damage
Other
Amount Claim
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6. Declaration
Has the insured, or anyone to be insured under this policy:
*
Yes
No
Had any insurance declined, cancelled, or refused renewal, had any special conditions/warranty imposed, or declined or refused a claim in the last 5 years?
7
8
Lodged a claim, notified an insurer or a potential claim, or is aware of an incident that may lead to claim under the Liability section of a policy in the last 5 years?
9
10
Lodged any claims in the 5 years (other than Liability claim)?
11
12
Been charged with or convicted of any criminal offence in the last 10 years (other than minor traffic convictions)?
13
14
Been declared bankrupt or even been involved in a company or business which became insolvent or subject to any form of insolvency administration (e.g. liquidation, receivership or voluntary administration)?
15
16
Upload images: Store front, Counter, Cash Register, Tobacco, Isles, From inside looking out (max 30 MB)
Click to upload store images
Store front, Counter, Cash Register, Tobacco, Isles, From inside looking out
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