(08) 6147 3200
ultra@uis.com.au
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Quote Form Liability
Contacts
Situation at Risk
Insurance Options
Insurance History
Additional Information
Contacts
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Next
Name
Email
Phone number/mobile
Date of birth
Relationship to business
Please select
Owner
Partner
Director
Staff
Admin
Management Company
Other
Describe other relationship to business
Are additional contacts required?
Yes
No
Additional Contacts
Additional Contacts #1
Name
Phone number/mobile
Email
Birth date
Relationship to business
Please select
Owner
Partner
Director
Staff
Admin
Management Company
Other
Describe other relationship
+ Additional Contacts
Business Details
Business structure
Company
Incorporated Association
Other
Partnership
Personal
Private Company (Pty Ltd)
Publicly Listed Company (Ltd)
Self Managed Superannuation Fund
Sole Trader
Superfund
Trust
Describe business structure
Company or Insured name
Trading as
ABN
Mailing address
Address Line 1:
Address Line 2:
Town/Suburb:
Postcode:
State:
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Registered for GST
Yes
No
Situation at Risk
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Next
Is the business address the same as the mailing address?
Yes
No
Business address
(Cannot be a PO Box)
Address Line 1:
Address Line 2:
Town/Suburb:
Postcode:
State:
Australian Capital Territory
New South Wales
Northern Territory
Queensland
South Australia
Tasmania
Victoria
Western Australia
Business location
Please select
Commercial unit
Standalone building
High rise building (3+ storeys)
Industrial area
Strip mall
Shopping centre with external frontage
Kiosk at shopping centre
Fully enclosed within a major shopping centre
Residential building
Other
Describe business location
Type of Occupancy
Please select
Owner Occupied
Rented by the Insured
Rented to Tenants
Other
Describe other occupancy type
Business Occupation
Business Occupation #1
What industry do you operating in?
Business Occupation/Activity
Please select
Accommodation
Accounting Services
Adhesive Manufacturing
Adult, Community and Other Education n.e.c.
Advertising Services
Aged Care Residential Services
Agricultural and Construction Machinery Wholesaling
Agricultural Machinery and Equipment Manufacturing
Air and Space Transport
Air Conditioning and Heating Services
Aircraft Manufacturing and Repair Services
Airport Operations and Other Air Transport Support Services
Alumina Production
Aluminium Rolling, Drawing, Extruding
Aluminium Smelting
Ambulance Services
Amusement and Other Recreational Activities n.e.c.
Amusement Parks and Centres Operation
Antique and Used Goods Retailing
Apple and Pear Growing
Architectural Aluminium Product Manufacturing
Architectural Services
Arts Education
Automotive Body, Paint and Interior Repair
Automotive Electrical Component Manufacturing
Automotive Electrical Services
Auxiliary Insurance Services
Bakery Product Manufacturing (Non-factory based)
Banking
Basic Inorganic Chemical Manufacturing
Basic Organic Chemical Manufacturing
Bauxite Mining
Beef Cattle Farming (Specialised)
Beef Cattle Feedlots (Specialised)
Beekeeping
Beer Manufacturing
Berry Fruit Growing
Biscuit Manufacturing (Factory based)
Boatbuilding and Repair Services
Boiler, Tank and Other Heavy Gauge Metal Container Manufacturing
Book and Magazine Wholesaling
Book Publishing
Bread Manufacturing (Factory based)
Bricklaying Services
Brothel Keeping and Prostitution Services
Building and Other Industrial Cleaning Services
Building Pest Control Services
Building Society Operation
Business and Professional Association Services
Cable and Other Subscription Broadcasting
Cafes and Restaurants
Cake and Pastry Manufacturing (Factory based)
Call Centre Operation
Car Retailing
Car Wholesaling
Carpentry Services
Casino Operation
Catering Services
Cement and Lime Manufacturing
Central Banking
Central Government Administration
Cereal Grain Wholesaling
Cereal, Pasta and Baking Mix Manufacturing
Cheese and Other Dairy Product Manufacturing
Child Care Services
Chiropractic and Osteopathic Services
Cigarette and Tobacco Product Manufacturing
Citrus Fruit Growing
Clay Brick Manufacturing
Cleaning Compound Manufacturing
Clothing and Footwear Repair
Clothing and Footwear Wholesaling
Clothing Manufacturing
Clothing Retailing
Clubs (Hospitality)
Coal Mining
Combined Primary and Secondary Education
Commercial Vehicle Wholesaling
Commission-Based Wholesaling
Communication Equipment Manufacturing
Computer and Computer Peripheral Retailing
Computer and Computer Peripheral Wholesaling
Computer and Electronic Office Equipment Manufacturing
Computer System Design and Related Services
Concrete Product Manufacturing
Concreting Services
Confectionery Manufacturing
Copper Ore Mining
Copper, Silver, Lead and Zinc Smelting and Refining
Corporate Head Office Management Services
Correctional and Detention Services
Corrugated Paperboard and Paperboard Container Manufacturing
Cosmetic and Toiletry Preparation Manufacturing
Cotton Ginning
Cotton Growing
Courier Pick-up and Delivery Services
Creative Artists, Musicians, Writers and Performers
Credit Reporting and Debt Collection Services
Credit Union Operation
Cured Meat and Smallgoods Manufacturing
Customs Agency Services
Cut and Sewn Textile Product Manufacturing
Dairy Cattle Farming
Dairy Produce Wholesaling
Data Processing and Web Hosting Services
Deer Farming
Defence
Dental Services
Department Stores
Diet and Weight Reduction Centre Operation
Directory and Mailing List Publishing
Document Preparation Services
Domestic Appliance Repair and Maintenance
Domestic Government Representation
Educational Support Services
Electric Cable and Wire Manufacturing
Electric Lighting Equipment Manufacturing
Electrical Services
Electrical, Electronic and Gas Appliance Retailing
Electricity Distribution
Electricity Transmission
Electronic (except Domestic Appliance) and Precision Equipment Repair
Electronic Information Storage Services
Employment Placement and Recruitment Services
Engineering Design and Engineering Consulting Services
Entertainment Media Retailing
Explosive Manufacturing
Farm Animal and Bloodstock Leasing
Fertiliser Manufacturing
Financial Asset Broking Services
Financial Asset Investing
Fire and Security Alarm Installation Services
Fire Protection and Other Emergency Services
Fish and Seafood Wholesaling
Fish Trawling, Seining and Netting
Fixed Space Heating, Cooling and Ventilation Equipment Manufacturing
Floor Coverings Retailing
Floriculture Production (Outdoors)
Floriculture Production (Under Cover)
Flower Retailing
Footwear Manufacturing
Footwear Retailing
Foreign Government Representation
Forestry
Forestry Support Services
Fossil Fuel Electricity Generation
Free-to-Air Television Broadcasting
Freight Forwarding Services
Fresh Meat, Fish and Poultry Retailing
Fruit and Vegetable Processing
Fruit and Vegetable Retailing
Fruit and Vegetable Wholesaling
Fuel Retailing
Funeral, Crematorium and Cemetery Services
Furniture and Floor Covering Wholesaling
Furniture Retailing
Garden Supplies Retailing
Gardening Services
Gas Supply
General Insurance
General Line Grocery Wholesaling
General Practice Medical Services
Glass and Glass Product Manufacturing
Glazing Services
Gold Ore Mining
Grain Mill Product Manufacturing
Grain Storage Services
Grain-Sheep or Grain-Beef Cattle Farming
Grape Growing
Gravel and Sand Quarrying
Hairdressing and Beauty Services
Hardware and Building Supplies Retailing
Health and Fitness Centres and Gymnasia Operation
Health Insurance
Heavy Machinery and Scaffolding Rental and Hiring
Higher Education
Hire of Construction Machinery with Operator
Horse and Dog Racing Administration and Track Operation
Horse Farming
Hospitals (Except Psychiatric Hospitals)
House Construction
Houseware Retailing
Human Pharmaceutical and Medicinal Product Manufacturing
Hunting and Trapping
Hydro-Electricity Generation
Ice Cream Manufacturing
Industrial and Agricultural Chemical Product Wholesaling
Industrial Gas Manufacturing
Internet Publishing and Broadcasting
Internet Service Providers and Web Search Portals
Interurban and Rural Bus Transport
Investigation and Security Services
Iron and Steel Casting
Iron and Steel Forging
Iron Ore Mining
Iron Smelting and Steel Manufacturing
Jewellery and Silverware Manufacturing
Jewellery and Watch Wholesaling
Justice
Kitchen and Diningware Wholesaling
Kiwifruit Growing
Knitted Product Manufacturing
Labour Association Services
Labour Supply Services
Land Development and Subdivision
Landscape Construction Services
Laundry and Dry-Cleaning Services
Leather Tanning, Fur Dressing and Leather Product Manufacturing
Legal Services
Libraries and Archives
Life Insurance
Lifting and Material Handling Equipment Manufacturing
Line Fishing
Liquor and Tobacco Product Wholesaling
Liquor Retailing
Local Government Administration
Log Sawmilling
Logging
Lottery Operation
Machine Tool and Parts Manufacturing
Magazine and Other Periodical Publishing
Management Advice and Related Consulting Services
Manchester and Other Textile Goods Retailing
Marine Equipment Retailing
Market Research and Statistical Services
Mattress Manufacturing
Meat Processing
Meat, Poultry and Smallgoods Wholesaling
Medical and Surgical Equipment Manufacturing
Metal and Mineral Wholesaling
Metal Coating and Finishing
Metal Furniture Manufacturing
Metal Roof and Guttering Manufacturing (except Aluminium)
Milk and Cream Processing
Mineral Exploration
Mineral Sand Mining
Mining and Construction Machinery Manufacturing
Motion Picture and Video Distribution
Motion Picture and Video Production
Motion Picture Exhibition
Motor Cycle Retailing
Motor Vehicle Body and Trailer Manufacturing
Motor Vehicle Dismantling and Used Parts Wholesaling
Motor Vehicle Manufacturing
Motor Vehicle New Parts Wholesaling
Motor Vehicle Parts Retailing
Museum Operation
Mushroom Growing
Music and Other Sound Recording Activities
Music Publishing
Natural Rubber Product Manufacturing
Natural Textile Manufacturing
Nature Reserves and Conservation Parks Operation
Newspaper and Book Retailing
Newspaper Publishing
Nickel Ore Mining
Non-Depository Financing
Non-Ferrous Metal Casting
Non-Financial Intangible Assets (Except Copyrights) Leasing
Non-Residential Building Construction
Non-Residential Property Operators
Non-Store Retailing
Nursery Production (Outdoors)
Nursery Production (Under Cover)
Nut, Bolt, Screw and Rivet Manufacturing
Office Administrative Services
Offshore Caged Aquaculture
Offshore Longline and Rack Aquaculture
Oil and Fat Manufacturing
Oil and Gas Extraction
Olive Growing
On Selling Electricity and Electricity Market Operation
Onshore Aquaculture
Optometry and Optical Dispensing
Administrative Services n.e.c.
Agricultural Product Wholesaling
Agriculture and Fishing Support Services
Allied Health Services
Automotive Repair and Maintenance
Auxiliary Finance and Investment Services
Basic Chemical Product Manufacturing n.e.c.
Basic Non-Ferrous Metal Manufacturing
Basic Non-Ferrous Metal Product Manufacturing
Basic Polymer Manufacturing
Building Installation Services
Ceramic Product Manufacturing
Construction Material Mining
Construction Services n.e.c.
Converted Paper Product Manufacturing
Crop Growing n.e.c.
Depository Financial Intermediation
Domestic Appliance Manufacturing
Electrical and Electronic Goods Retailing
Electrical and Electronic Goods Wholesaling
Electrical Equipment Manufacturing
Electricity Generation
Electronic Equipment Manufacturing
Fabricated Metal Product Manufacturing n.e.c.
Fishing
Food Product Manufacturing n.e.c.
Fruit and Tree Nut Growing
Furniture Manufacturing
Gambling Activities
Goods and Equipment Rental and Hiring n.e.c.
Goods Wholesaling n.e.c.
Grain Growing
Grocery Wholesaling
Hardware Goods Wholesaling
Health Care Services n.e.c.
Heavy and Civil Engineering Construction
Horse and Dog Racing Activities
Information Services
Interest Group Services n.e.c.
Livestock Farming n.e.c.
Machinery and Equipment Manufacturing n.e.c.
Machinery and Equipment Repair and Maintenance
Machinery and Equipment Wholesaling n.e.c.
Manufacturing n.e.c.
Metal Container Manufacturing
Metal Ore Mining
Mining Support Services
Motor Vehicle and Transport Equipment Rental and Hiring
Motor Vehicle Parts Manufacturing
Non-Metallic Mineral Mining and Quarrying
Non-Metallic Mineral Product Manufacturing
Personal Accessory Retailing
Personal Services n.e.c.
Petroleum and Coal Product Manufacturing
Polymer Product Manufacturing
Professional and Scientific Equipment Manufacturing
Professional, Scientific and Technical Services n.e.c.
Public Order and Safety Services
Publishing (except Software, Music and Internet)
Repair and Maintenance n.e.c.
Residential Building Construction
Residential Care Services
Social Assistance Services
Specialised Design Services
Specialised Food Retailing
Specialised Industrial Machinery and Equipment Wholesaling
Specialised Machinery and Equipment Manufacturing
Store-Based Retailing n.e.c.
Structural Metal Product Manufacturing
Telecommunications Network Operation
Telecommunications Services
Transport Equipment Manufacturing n.e.c.
Transport n.e.c.
Transport Support Services n.e.c.
Warehousing and Storage Services
Waste Collection Services
Water Transport Support Services
Wood Product Manufacturing n.e.c.
Packaging Services
Paint and Coatings Manufacturing
Painting and Decorating Services
Paper Bag Manufacturing
Paper Product Wholesaling
Paper Stationery Manufacturing
Parking Services
Passenger Car Rental and Hiring
Pathology and Diagnostic Imaging Services
Performing Arts Operation
Performing Arts Venue Operation
Pesticide Manufacturing
Petroleum Exploration
Petroleum Product Wholesaling
Petroleum Refining and Petroleum Fuel Manufacturing
Pharmaceutical and Toiletry Goods Wholesaling
Pharmaceutical, Cosmetic and Toiletry Goods Retailing
Photographic Chemical Product Manufacturing
Photographic Film Processing
Photographic, Optical and Ophthalmic Equipment Manufacturing
Physiotherapy Services
Pig Farming
Pipeline Transport
Plaster Product Manufacturing
Plastering and Ceiling Services
Plumbing Goods Wholesaling
Plumbing Services
Police Services
Polymer Film and Sheet Packaging Material Manufacturing
Polymer Foam Product Manufacturing
Port and Water Transport Terminal Operations
Postal Services
Post-production Services and Other Motion Picture and Video Activities
Potato, Corn and Other Crisp Manufacturing
Poultry Farming (Eggs)
Poultry Farming (Meat)
Poultry Processing
Prawn Fishing
Prefabricated Metal Building Manufacturing
Prefabricated Wooden Building Manufacturing
Prepared Animal and Bird Feed Manufacturing
Preschool Education
Primary Education
Printing
Printing Support Services
Private Households Employing Staff
Professional and Scientific Goods Wholesaling
Professional Photographic Services
Psychiatric Hospitals
Pubs, Taverns and Bars
Pulp, Paper and Paperboard Manufacturing
Pump and Compressor Manufacturing
Radio Broadcasting
Rail Freight Transport
Rail Passenger Transport
Railway Rolling Stock Manufacturing and Repair Services
Ready-Mixed Concrete Manufacturing
Real Estate Services
Reconstituted Wood Product Manufacturing
Regulatory Services
Religious Services
Reproduction of Recorded Media
Residential Property Operators
Retail Commission-Based Buying and/or Selling
Rice Growing
Rigid and Semi-Rigid Polymer Product Manufacturing
Road and Bridge Construction
Road Freight Transport
Rock Lobster and Crab Potting
Roofing Services
Rope, Cordage and Twine Manufacturing
Sanitary Paper Product Manufacturing
Scenic and Sightseeing Transport
Scientific Research Services
Scientific Testing and Analysis Services
Seafood Processing
Secondary Education
Sewerage and Drainage Services
Shearing Services
Sheep Farming (Specialised)
Sheep-Beef Cattle Farming
Sheet Metal Product Manufacturing (except Metal Structural and Container
Shipbuilding and Repair Services
Silver-Lead-Zinc Ore Mining
Site Preparation Services
Soft Drink, Cordial and Syrup Manufacturing
Software Publishing
Solid Waste Collection Services
Special School Education
Specialist Medical Services
Spirit Manufacturing
Sport and Camping Equipment Retailing
Sports and Physical Recreation Administrative Service
Sports and Physical Recreation Clubs and Sports Professionals
Sports and Physical Recreation Instruction
Sports and Physical Recreation Venues, Grounds and Facilities Operation
Spring and Wire Product Manufacturing
State Government Administration
Stationery Goods Retailing
Steel Pipe and Tube Manufacturing
Stevedoring Services
Stone Fruit Growing
Structural Steel Erection Services
Structural Steel Fabricating
Sugar Cane Growing
Sugar Manufacturing
Superannuation Funds
Supermarket and Grocery Stores
Surveying and Mapping Services
Synthetic Resin and Synthetic Rubber Manufacturing
Synthetic Textile Manufacturing
Takeaway Food Services
Taxi and Other Road Transport
Technical and Vocational Education and Training
Telecommunication Goods Wholesaling
Textile Finishing and Other Textile Product Manufacturing
Textile Floor Covering Manufacturing
Textile Product Wholesaling
Tiling and Carpeting Services
Timber Resawing and Dressing
Timber Wholesaling
Toy and Game Retailing
Toy and Sporting Goods Wholesaling
Toy, Sporting and Recreational Product Manufacturing
Trailer and Other Motor Vehicle Retailing
Trailer and Other Motor Vehicle Wholesaling
Travel Agency and Tour Arrangement Services
Turf Growing
Tyre Manufacturing
Tyre Retailing
Undifferentiated Goods-Producing Activities of Private Households for Own Use
Undifferentiated Service-Producing Activities of Private Households for Own Use
Urban Bus Transport (Including Tramway)
Vegetable Growing (Outdoors)
Vegetable Growing (Under Cover)
Veneer and Plywood Manufacturing
Veterinary Pharmaceutical and Medicinal Product Manufacturing
Veterinary Services
Video and Other Electronic Media Rental and Hiring
Waste Remediation and Materials Recovery Services
Waste Treatment and Disposal Services
Watch and Jewellery Retailing
Water Freight Transport
Water Passenger Transport
Water Supply
Whiteware Appliance Manufacturing
Wine and Other Alcoholic Beverage Manufacturing
Wired Telecommunications Network Operation
Wood Chipping
Wooden Furniture and Upholstered Seat Manufacturing
Wooden Structural Fitting and Component Manufacturing
Wool Scouring
Wool Wholesaling
Zoological and Botanical Gardens Operation
Other
Do you do any other business/occupation activities?
Does this occupation involve any of the following activities?
Welding / hot work
Woodworking
Spray painting
Hiring out equipment and/or staff
Storage or handling of dangerous goods
Working with heights over 5 metres
Importing/Exporting
+ Business Occupation
How long has the business been operating?
Please select
New Venture - Not Previously Employing
Less than 1 year
1 to 2 years
2 to 3 years
3 to 4 years
4 to 5 years
Over 5 years
Estimated annual gross turnover
$
Estimated annual gross wages
$
Full-time staff
Part-time staff
Is there an interested to be noted? i.e. landlord, principal contract, etc.
Yes
No
Interested party type
Please select
Principal Contractor
Landlord
Lessor
Other
Describe interested party
Interested party name
Insurance Options
Previous
Next
Please select all cover options required
Public and Products Liability
General Property
Public/Products Liability - Additional Questions
Public liability
Please select
$5,000,000
$10,000,000
$20,000,000
$50,000,000
Products liability
Please select
$5,000,000
$10,000,000
$20,000,000
$50,000,000
Property in physical and legal control
Does the Insured require cover only as a Property Owner? (Excl. other business activities)
Yes
No
Does the Insured import and products or raw materials?
Yes
No
Please provide additional information
Does the Insured export any products or raw materials?
Yes
No
Please provide additional information
Does the Insured employ sub-contractors or labour hire personnel?
Yes
No
Please provide additional information
Estimated annual payments to sub-contractors
$
Estimated annual payments to labour hire personnel
$
Does the Insured ensure sub-contractors and/or labour hire personnel have their own public liability insurance and workers compensation where applicable?
Yes
No
General Property - Additional Questions
Unspecified portable valuables / general property sum insured (electronic items, tools, etc.) - a sub-limit for any one item may apply
$
Specified general property (greater than $2000)
Description
Sum insured
$
+/-
Insurance History
Previous
Next
In the last 5 years have you
i. had insurance refused, cancelled, declined, or special terms imposed?
Yes
No
ii. been declared bankrupt, placed in liquidation, receivership, or voluntary administration?
Yes
No
iii. been convicted of or had any fines imposed for any crime involving drugs, dishonestly, arson, theft, fraud, or violence against any person or property, including association with Outlaw Motorcycle Gangs or Organised Crime Gangs?
Yes
No
If yes to any of the above questions, please provide details. Alternatively, call us on (08) 6147 3200.
Claims History
In the last five years has the owner or business suffered any loss or claims made against you that has not already been declared?
Yes
No
List any claims from the last 5 years
Insurer
Claim date
Type of claim
Amount paid
Finalized
Description
Please select
Product Liability
Property Damage
Public/Product liability
Personal Injury
Other
$
Please select
Finalized
Not Finalized
Additional Information
Previous
Submit
Please provide any additional information relevant to your risk, or additional covers you may require
Policy effective date
Policy expiry date
Would you like to pay monthly?
Yes
No
Who is your current insurer?
What is your current premium?
$
What is your current excess?
$
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