IUA Interruption Underwriting Agencies

All quotations are subject to Underwriter's acceptance.

This form is designed for the simpler, lower values risks. For other risks, we may ask you for additional information.

From the information shown please provide:
QuotationAdviceCover Note

Required fields *
Broker:*
Contact:*
Email Address:*
Telephone:
Insured:
Trading Name:

	Premises 1	Premises 2	Premises 3	Premises 4
Address Line 1:
Suburb:
State:
Postcode:
Details of Construction: (Walls/Floor/Roof)

Occupation/Business:
In Business:	years
Other Interested Parties:
Material Damage Insurer:
Claims History: (all classes) 5 years
Annual Turnover:	$
Rating Classification (if known):	%

Item	Particulars of Insurance Required			Limit of Sum Insured ($)
1		Weeks of Indemnity	Weekly Sum Insured
		weeks	$
Limit of Liability for Item 1				$
2	Seasonal Trading
		Weeks of Indemnity weeks	Weekly Sum Insured $
Limit of Liability for Item 2 (Seasonal Trading)				$
3	Loss of Rent or Rental Value
		Weeks of Indemnity weeks	Weekly Sum Insured $
Limit of Liability for Item 3 (Loss of Rent)				$
4	Lumped Extensions (Increased or additional cost of working necessarily incurred)
Limit of Liability for Item 4 ("Lumped Extensions")				$
5	Other As Defined
Limit of Liability for Item 5				$
Maximum Liability				$

Comments: