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SME Insurance :: KlaptonOnline
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SME Insurance Application Form
Note: * Indicates required field.

Broker

Applicant Information

Business Information

Class of business :
Building is built of :

Requested Coverage

Information Disclosure and Accuracy

Applicant Declaration:

  1. I hereby declare and certify that I or the business this application is submitted for have not been rejected or declined by an insurance company for Insurance Cover.
  2. No insurance company ever cancelled an insurance policy or coverage issued in my name or in the name of the proposed business or in the name of another business owned or managed by me.
  3. No claim has been filed against an insurance company by the business proposed for insurance or by me for same type of coverage now being proposed for coverage and no claim was submitted or filed or made against the business proposed for insurance, in the past 3 years.
  4. Neither I nor the business proposed for insurance have waived any subrogation rights against any third party or agreed with any third party to waive any future rights of subrogation. Neither I nor the business proposed for insurance or any employee of mine or of the business proposed for insurance been convicted of any criminal offense, other than traffic violation in the past 5 years.
  5. If the business proposed for insurance legally needs any local license or permit, it is declared and certified that such license is obtained and valid.
  6. I hereby declare and certify that all the information, answers and details provided above are full, true and honest, and that they provide full disclosure of the information regarding the risks submitted for coverage or quote.

By checking this box I confirm and declare my agreement with all the details and declarations contained in the various declarations above.

Submitted Date: 16 Sep 2019