Any single loss of money ie. cash, and currency notes, money orders, securities for money, current postage and revenue stamps and unexpired units in franking machines all secured in locked safe or strong room whilst on the premises out of business (hours)

Any single loss of such Money NOT secured in locked safe or strongroom whilst on the premises out of business hours.

Any single loss of Money in a residence of any principal or employee of the proposer

In respect of any other single loss of money.

Please state the estimated amount of Money (other than non-negotiable cheques or similar instruments) to be carried in transit in connection with your business for the next 12 months.

1. What is the approximate distance to your bank(s) from your premises

2. How are the journeys made(eg. on foot, by car or security company)?

3. How many adult employees accompany the Money during transportation?

4. Give details of any other special precautions taken during transportation of Money:

5. Is your money carried to / from any other premises besides the bank
yesno

6. Are your premises occupied at night? if yes, by whom?

7. Do you wish to insure against bodily injury consequent upon assault by thieves?

8. Are your premises in your sole occupation? If not, give details

9. Please give the following particulars of all safes and strongrooms:

(a) Maker's name and date of manufacture:

(b) Weight and dimensions:

(c) Anchored to ground or freestanding:

(d) Current value of safe(s) and strongroom(s):

(e) Are all keys of all safes and strongrooms removed from your premises when the premises are closed for business?

10. Are your premises fitted with a burglar alarm?If yes, give particulars

11.Have you ever sustained any losses in respect of any of the risks against which you now wish to insure? If yes, give full details:

12. Has any insurer declined to accept, cancelled, refused to continue or agreed to continue only on special terms any insurance for you?
yesnow

DECLARATION:



I/We hereby declare that to the best of my / our knowledge and belief the answers given by me/us in this form are true



Submitting this form does not bind your to complete the insurance nor NCCI to accept, but it is agreed that this form shall be the basis of the contract should a policy be issued.