Engineering: Machinery Breakdown Insurance

Client Code*

Name of person completing questionnaire*

Insured Name*

1. Have you purchased any machinery / equipment in the last policy period?*

Yes
No

If YES, please advise full details.

If you require any assistance or wish to discuss any element of the policy please contact us as we will assist you wherever possible.

Claims

2. Details of any claims that have occurred, but have not yet been reported*

3. After specific inquiry, details of any facts, circumstances or incidents (other than those already disclosed, notified to your insurer) which could give rise to claims in the future.*

Information we have provided to Sarina Insurance Brokers, is to the best of our knowledge correct. Please type your name below:*

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Engineering: Machinery Breakdown Insurance

Claims

Sarina Insurance

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