Policy Period
From:
Today’s
Date:
To:
Insured Details
Insured 1 Name:
Date of Birth:
Insured 2 Name:
Date of Birth:
Postal Address:
Retired:
Suburb:
State:
Phone No.:
Post Code:
Fax No.:
E-mail:
Situation Address
Address:
Suburb:
Building Cover Amount
State:
Post Code:
TOTAL Contents Cover Amount (including listed contents if taken)
$
$
Optional Listed Contents
Insured Value
Item Description
$
$
$
If the home or contents subject to any loan or finance, please list the full Interested Party(s) to be noted
Type of Cover
Occupied by
Alarm
Smoke Detectors
Rent: $
Managed:
Building Type
Building Security
Building Construction
Roof:
Walls:
Floor:
Age:
Size:
Building History Questions
Has the building or land ever been flooded?
Has the building been Rewired in the last 25 years?
Has the building been Replumbed in the last 25 years?
Does this building have safety switches?
Does the property exceed 2 hectares (5 acres)?
Is this building connected to Town Water?
Is the building used for Business purposes?
square meters
Is the building used for the purpose of farming?
Is the building currently under construction or renovation?
Is the home Heritage Listed?
Is the home currently insured?
Will the premises be unoccupied for more than 60 consecutive days?
Is your home or the area within 250 meters of the home ever been affected by flooding?
Is the home within 250 meters of any named natural water course?
Double cylinder deadlocks on all external doors, including patio bolts on any external sliding doors?
All windows key locked or have bars/grilles?
Important Disclaimer Questions
Have you ever been refused insurance; been declined renewal of insurance; or had any special
terms or conditions imposed?
Have you been charged or convicted during the last 5 years of arson or any offence involving actual
or threatened damage to property; any criminal act; fraud; theft; drugs; or dishonesty of any kind?
Are there any exceptional circumstances you know about which are relevant to our decision to
insure you?
Details of all Claims and Amount Paid in last 5 years. If you have had none, write ‘None’
Date
Details
Amount Paid
$
$
$
Additional Details
Please Save This Form and Send Back
As Attachment, to [email protected]