Please complete our online application form to receive an insurance quote. Submission of this application does not automatically insure you, we will be in contact to offer a quote or seek further information first. Name of Insured/Business:* Address:* Post code Contact:* Phone: Email:* VEHICLE DETAILS TRAILER VAN Year* Make* Model* Number of Axles* Rego No* Value of Vehicle $* For vehicles over 30 years, Please confirm when all the critical components such as brakes, wiring & Tyres have been updated Is your vehicle built with EPS / Coolroom Panels*These panels are single piece factory engineered units typically comprised of two metal faces bonded to a fully insulating core. Yes No Modifications / Fixed Equipment / Fit Out Value of Fit Out $* TOTAL SUM INSURED $ Is the Trailer fitted with a Wheel Clamp or Two Hook Lock? Yes No Type* Where is the vehicle kept overnight Postcode Garage Driveway Carport Street Finance* Yes No Finance Company* Do you use any Deep Fry Appliances* Yes No If Yes* Bench top Built In If Yes, Please Confirm* Number of Units Type: Gas Electric Number of Bays/Liters CONTENTS (Separate Policy Required)Non Fixed Contents (Please Specify with Value) DRIVERSDrivers: Please supply Details of all drivers*NameDate of Birth HistoryNo Claim Bonus (Subject to Written Confirmation) Nil/6 20%5 30%4 40%3 50%2 60%1 In the last 5 years have you hadDRIVER 1 - Accidents or Claims* Yes No DRIVER 2 - Accidents or Claims Yes No DRIVER 1 - Traffic Offences (excluding parking)* Yes No DRIVER 2 - Traffic Offences (excluding parking) Yes No DRIVER 1 - Licence Cancelled / Endorsed / Suspended* Yes No DRIVER 2 - Licence Cancelled / Endorsed / Suspended Yes No DRIVER 1 - Insurance Refused / Declined / Cancelled* Yes No DRIVER 2 - Insurance Refused / Declined / Cancelled Yes No DRIVER 1 - Criminal Convictions* Yes No DRIVER 2 - Criminal Convictions Yes No DRIVER 1 - If yes to any of the above please give full details*DRIVER 2 - If yes to any of the above please give full details*PUBLIC AND PRODUCTS LIABILITY Option A - $10,000,000 Public and Products Liability Option B - $20,000,000 Public and Products Liability Number of Food Vans / Trailers used in connection with your business Full Descriptions of Food soldEstimated Gross Annual Sales $ Are any products IMPORTED or EXPORTED by you / your business?* Yes No If Yes, Please attach a detailed list of each product imported / exported and the country of origin / destinationMax. file size: 8 MB.a) Are you or have you previously been insured against the risks to be insured?* Yes No b) Have you had any claims made against you (whether insured or not)?* Yes No c) Have you had any incident or accident occur which would have been covered by the proposed insurance policy?* Yes No d) Have you had any insurance declined or cancelled, proposal rejected, renewal refused, claim rejected, special Conditions or special excesses imposed by an insurer?* Yes No e) Have you ever been convicted of a criminal offence?* Yes No Please add photos of your food van(s) if possible. Drop files here or Select files Max. file size: 8 MB. General CommentsName:* Signature*Date* DD slash MM slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
