Main Contact – Name(s)

Email

Phone Number

Postal Address

Insured Name 1 Name

Insured Name 2 Name

Insured Address

Building Age
Choose one0–5 years6–10 years11–20 years21-30 years31-40 years41-50 years51-60 years61-70 years71-80 years

External Wall Construction

Floor Construction

Roof Construction

Number of Levels with ground being 1
1234

Completed any renovations?

Bedrooms
123456+

Bathrooms
12345+

Occupancy
Owner and FamilyWe are tenants

Connected to Town Water
YesNo

Tank Water
YesNo

Pool or Spa?
YesNoI wish!

Security
Deadlocks on all external doorsSecurity Screens on all external doorsWindow Bars/ScreensLocal Alarm or Monitored by InsuredMonitored Alarm by Third Party CompanySecuirty FenceCCTV

Highly Combustible Material (e.g. EPS or ACP)
YesNoUnsure

Asbestos Present?
YesNoUnsure

Roller Doors
NoneInstalled before 2012, no bracingInstalled after 2012

Shed/s
NoneSmall garden shed, not built to cyclone standardLarge, built to cyclone standard

Bushfire Protection

Backflow Valve
YesNoUnsure

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Building Replacement Value

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Contents Replacement Value

Specified Contents

Specified Valuables

Previous Claims Declined?
Please SelectYesNoLet's Discuss

Ever been liable for any civil offence or pecuniary penalty?
Please SelectYesNoLet's Discuss

Ever been charged or convicted of a criminal offence?
Please SelectYesNoLet's Discuss

Ever had an insurance policy cancelled, declined or terms imposed?
Please SelectYesNoLet's Discuss

Aware of circumstances which could give rise to a claim?
Please SelectYesNoLet's Discuss

Anything to Declare under Duty of Disclosure?
Please SelectYesNoLet's Discuss

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