AMA Queensland Insurance Solutions

Medical Centre/Practice Insurance Enquiry Form

Insured Name:

Situation address:

Business activities:

Medical Centre
Specialist Centre
X-Ray
Pathology
Other

Please nominate the value of each of the following you wish to have covered: (please tick boxes where appropriate and nominate the full replacement value)

Fire Cover:

Building	$
Contents	$
Stock	$

Burglary/Theft:

Contents	$
Stock (incl. vaccines & refrigerated goods)	$

Portable Property:

Laptops	$
Mobile phones	$
PDAs	$
Medical equipment	$
Other	$

Business Interruption:
(Provides cover for the interruption or interference to the business caused by loss or damage to property insured for Fire, Theft or other defined events.)

Gross Practice income $

Glass cover:

Replacement value

Money cover:

$20,000 automatic cover
Other $

Public Liability Indemnity:

Limit		$5 Million
		$10 Million
		$20 Million

Construction of building:

Walls:	Brick	Concrete	Timber	Other
Floor:	Concrete	Timber
Roof:	Tile	Metal

Do you own the building?

Yes No

Age of building:

years

Fire protection:

	Nil
	Fire extinguishers & hose reels
	Local smoke detectors
	Monitored smoke detectors
	Sprinkler system

Burglary protection:

	Nil
	Deadlocks on doors
	Keyed window locks
	Bars on windows
	Local alarm
	Monitored alarm
	Other

Business Location:

	Suburban street
	Main street
	Strip shopping centre
	Fully enclosed within a major shopping centre or other building (no external access)

Adjoining Premises:

	Nil
	Retail/offices
	Restaurant
	Other

Annual turnover:

No. of employees:

Have you had any claims in the last 5 years?

Yes No

If yes, claims details:

Name of current insurer:

Cover expiry date:

Contact Details

Name:

Preferred method of contact:

	Email
	Phone
	Fax
	Post

Phone:

Fax:

Mobile:

Email Address:

Preferred time to contact: