Rural Questionnaire

Chinchilla
113 Heeney Street, Chinchilla QLD 4413
PO Box 894
Tel: 07 4668 9196
Fax: 07 4668 9292
Email: admin@axiominsurance.com.au

Toowoomba
418 Ruthven Street, Toowoomba QLD 4350
PO Box 962
Tel: 07 4638 8600
Fax: 07 4638 8611
Email: admin@axiominsurance.com.au

Farm Name	Number/Lot	Street/Road Name	State	Postcode	Size (hectares)

Farm Building Description (Eg machine shed, hay shed, etc)	Construction/Details	Year Built	Sum Insured ($)

Make	Model	Year	Description	Sum Insured $	Rego	NCB

Year	Type	Description	Sum Insured $	Rego

Year	Type	Make	Model	Description	Sum Insured $	Rego	NCB

Who This Enquiry Is For

Date of claim	Type of loss or Damage (Eg. Fire, Water Damage etc)	Amount ($)

Nature of Work	Previous 12 Months ($ )	Next 12 Months ($)

Nature of Work	Previous 12 Months ($ )	Next 12 Months ($)