To :

Of:

Fax :

From :

Fax : 03 9791 6633

COMMERCIAL NEEDS ANALYSIS

Proposer Name(s) Or Company Name:

Trading Name:

Contact Name:

Phone:

Facsimile:

List all directors names or partners names & all relevant qualifications / experience in this type of business?:

Directors / Partners Names

Position Held

Relevant Qualifications

Previous Relevant Experience

How many years has this business been operating?

What was your previous business?

ABN No.

If you are not claiming 100% input tax credits for GST please state %?

Website:

www.

Our Occupation Is?

Describe all day to day activities of your business?

Are you?

Manufacturers

Importers

Exporters

Retailers

Wholesalers

Tradesmen

Builders

Installers

Repairers

Offices

Do you sub contract work to others?

And what type of work is sub contracted?

Do you check that sub contractors have liability insurance & when do you check?

Do you have property of others on your premises in your physical & legal control?

Give Details?

List your major products?

Do you intend to launch any major new products in the next 12 months?

Give Details?

Do you have quality control procedures in place for checking your products are safe?

Give Details?

List the main objectives / goals of your business over the next 3 years?

List briefly your business insurance needs / covers required?

(Tick)

Fire & Perils

Machinery Breakdown

Professional Indemnity

Business Interruption

Spoilage Of Food

Directors & Officers Indemnity

Public &/or Products Liability

Computer Breakdown

Trade Debtors Protection

Burglary

Fidelity Guarantee

Marine Cargo / Transit

Money

TaxAudit

Tools In Transit

General Property

Plant and/or Equipment

Carriers Indemnity

Other insurance covers you should consider to protect your business and personal income?

Business Motor

Accident/Sickness

Income Protection

Motor Fleet / Schedule

Private Motor

Keyman/Life

Group Travel

Home & Contents

Trauma Recovery

Group Accident

Landlords

Superannuation

Commercial Strata

Residential Strata

Rollovers

Employer Practices Liability

Caravan

Business Loans

Workcover

Pleasure Boat

Housing Loans

Other:

Farm/Rural

Financial Planning

If you are not currently insured for Business Interruption / Loss Of Profits please explain why?

In the last financial year did your books of account show a net profit? (Income less Expenditure)

If not, explain why?

Other Information :

- Insurance declined, cancelled, or special terms imposed?

- Charged of any criminal offence or bankruptcy?

- Suffered any claims in the last 5 years?

If YES, Give Details :

Is there any additional information that needs to be disclosed to us?

IMPORTANT DECLARATION BY CLIENT

Under the new financial services legislation insurance brokers are required to obtain additional information to assist us in providing

advice in relation to your business. We rely on the answers to the questions above in our decision making process in respect

of your insurances.

If you elect not to answer some of the questions we may not be able to provide with advice under the Act.

I/we in arranging insurance / quotations, in accordance with the information furnished in this Needs Analysis / Fact Finder

declare and warrant that:

(a) The statements in this Needs Analysis / Fact Finder are true & correct.

(b) I/we have disclosed all matters which to my/our knowledge you should be aware of and in particular, I/we have

fully disclosed my Objectives, Financial Situation and Needs relevant to this insurance.

any Policy held by me/us.

(d) That I/we agree to accept the terms, exclusions, conditions and limitations of the Policy(s) effected on my behalf by

you in respect of the insurances obtained in respect of the above.

Client/Proposer(s) Signature: …………………………………………………………

Date: ….……/…………/……………

Office Use (Tick):

Complete Advice

Limited Advice

No Advice Sale

Statement of Advice (Recommendations/Limitations) to Client: