VIP Home Cleaning Insurance Questionnaire

Franchise Entity

ABN

Contact Person

First Last

Date of Birth

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Business Details

Estimated Annual Turnover

Number of Employees

Please list all services provided

Are your business activities restricted to the day to day cleaning activities of someone’s domestic home?

Yes
No

Do you clean any commercial properties?

Yes
No

Please provide details about the commercial properties

Limit of Public & Products Liability Required

$10,000,000
$20,000,000

Do you use any sub-contractors?

Yes
No

What are your annual payments to sub-contractors?

Tools & Equipment, level of cover required

$2,000
$5,000
$10,000

Do you have any equipment valued over $2,500 any one item?

Yes
No

Please list and provide value of this equipment

Would you like $10,000 Tax Audit Cover

Yes
No

Disclosure Questions

In 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?

Yes
No

In the last 5 years have you ever been placed in receivership or liquidation or been declared bankrupt?

Yes
No

In 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?

Yes
No

In the past 3 years, have you had any claims in relation to Liability or Tools & Equipment?

Yes
No

Please provide details including dates, values and full description

Declaration

Signature

Date

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.