Brothel Tenant Declaration

Please complete the fields and declaration below. To ensure your submission reaches your insurance broker, please include their name and email address.

Broker name(Required)

Broker email address(Required)

Business name(Required)

Business address(Required)

Street Address City State Postcode Country

ABN(Required)

Name of Building Owner(Required)

First Last

Declaration(Required)

Select exactly 3 choices.

I declare that my/our business and/or partner(s) have NO affiliations with any Outlaw Motor Cycle Gang (OMCG), nor any memberships with any motorcycle social clubs.

We are a legal operation and hold the relevant license applicable to our occupation and business activities.

We don’t use flame candles anywhere on the premises.

Name(Required)

Position(Required)

Signature(Required)

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