About this form

The information you provide in this Application Form will help Kobe assess your insurance needs. It will also be shared with underwriters to help source the best cover for you. Please complete this openly and honestly because you do have a Duty of Disclosure.

Duty of Disclosure

Before submitting this application, we have to tell you about your duty of disclosure at law which applies until an insurer agrees to insure you.

We will ask you questions that are relevant to our decision to insure you and on what terms. When answering our questions, you must tell us anything that you know and that a reasonable person in the circumstances would include in their answer. If you do not tell us anything you are required to, we may cancel your policy or reduce your claim, or both. If your failure is fraudulent, we may refuse to pay your claim and avoid the policy altogether.

Privacy Policy

By submitting this form, the personal information you provide to Kobe Insurance Pty Ltd in this form or otherwise may be collected, held, used and disclosed in the manner set out in the Kobe Insurance Services Privacy Policy, including for the processing of this application and providing cover.

Duty of Disclosure Acknowledgement *

I acknowledge my duty of disclosure

Client Details

First Name *

Last Name *

Phone

Mobile *

Fax

Email *

Website

Business/Trading Name

ABN

Single Checkbox Field

GST Regsitered

Location(s)

Details of the Business

Is the premise currently occupied?

By whom?

Tenant
Owner occupied
Owner

Are you the Property Owner of the Venue?

If No, is cover required for the Property Owner under this Policy? *

Period of Insurance Start Date

(12 months cover)

From *

Description of Trade or Business (Please attach brochures if available)

Location of Premises (attach a list if more than one location)

Limit of Indemnity Required

General Liability - Limit any one occurrence

Products Liability - Aggregate Limit in each period of insurance

Goods in Care Custody & Control

Products (Give details of all products to be covered by this insurance - attach brochures and technical information)

Turnover for the current financial year

Actual turnover for the last financial year

Are the Products Sourced Locally

If no please advise the country imported from

How often does your product range change?

Give details of your quality control and testing procedures

Do you employ contractors, subcontractors and/or labour hire employees?

If yes, please advise the activities they perform and their value ($) *