VIP Commercial Cleaning Insurance Questionnaire Franchise EntityABNContact Person First Last Date of Birth Date Format: DD slash MM slash YYYY Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country PhoneEmail Business DetailsEstimated Annual TurnoverNumber of EmployeesPlease list all services providedDoes your business clean, childcare centres, or medical centres? If yes, this must be done after trading hours and no disposal of sharps.YesNoDoes your business clean shopping centres/carparks or retail shops within shopping centres?YesNoPlease provide details about these businesses you cleanDoes your business clean hospitals, refineries, stations, piers, wharves, mines or airports?YesNoPlease provide detils about this cleaning?Does your business clean before or during trading hours?YesNoPlaese provide extra detailsLimit of Public & Products Liability Required$20,000,000Do you use any sub-contractors?YesNoWhat are your annual payments to sub-contractors?Tools & Equipment, level of cover required$2,000$5,000$10,000Do you have any equipment valued over $2,500 any one item?YesNoPlease list and provide value of this equipmentWould you like $10,000 Tax Audit CoverYesNoDisclosure QuestionsIn the last 5 years, have you had any insurer decline a claim or proposal, cancel or refuse to renew a policy, or impose special terms, conditions or restrictions on a policy?YesNoIn the last 5 years have you ever been placed in receivership or liquidation or been declared bankrupt?YesNoIn the last 10 years, have you been convicted of, or had any penalties imposed, for any crimes involving drugs, dishonesty, arson, theft, fraud or violence against any person or property?YesNoIn the past 3 years, have you had any claims in relation to Liability or Tools & Equipment?YesNoPlease provide details including dates, values and full descriptionDeclarationSignatureDate Date Format: DD slash MM slash YYYY Signature consent This electronic signature will be treated the same as if signed personally (tick to sign)* Once your Insurance Policy is confirmed, Yes Cover will provide VIP Head Office with a copy of your Certificate of Currency.
