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Certificate of Currency
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Home & Contents
Home Insurance Form
Insured Name 1
Insured Name 2
Email
Phone Number
Insured Address
Address Line 1
Address Line 2
City
State
Area Code
Type of Cover
- Select -
Home Only
Contents Only
Home and Contents
Building Age
- Select -
1890
1891
1892
1893
1894
1895
1896
1897
1898
1899
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
External Wall Construction
- Select -
Timber
Weatherboard
Asbestos
Fibro
Brick
Block
Tilt Concrete
Metal
Other
Floor Construction
- Select -
Concrete
Timber
Other
Roof Construction
- Select -
Metal
Colorbond
Tile
Asbestos
Other
Number of Levels
- Select -
Ground Only
Ground plus 1
Ground plus 2
Ground plus 3
Renovations since original build
Number of Bedrooms
- Select -
1
2
3
4
5
6
Number of Bathrooms
- Select -
1
2
3
4
5
Occupancy
- Select -
Owner and Family
We are Tenants
Connected to Town Water
Yes
No
Tank Water
Yes
No
Pool or Spa
- Select -
Pool Only
Spa Only
Pool and Spa
Security
Deadlocks on all external doors
Security Screens on all external doors
Window Bars/Screens
Local Alarm or Monitored by Insured
Monitored Alarm by Third Party Company
Security Fence
CCTV
Highly Combustible Material (e.g. EPS or ACP)
- Select -
Yes
No
Unsure
Asbestos Present
- Select -
Yes
No
Roller Doors
- Select -
None
Installed before 2012, no bracing
Installed after 2012
Shed(s)
- Select -
None
Small Garden Shed, not built to cyclone standard
Large Shed, built to cyclone standard
Bushfire Protection
- Select -
Yes
No
Backflow Valve
Yes
No
Unsure
Building Insurance Replacement Value
Contents Replacement Value
Specified Contents (high value item at property)
Specified Valuables (High Value Item that are Taken away from Insured Address)
Previous Claims Declined?
- Select -
Yes
No
Ever been liable for any civil offence or pecuniary penalty?
- Select -
Yes
No
Ever been charged or convicted of a criminal offence?
- Select -
Yes
No
Ever had an insurance policy cancelled, declined or terms imposed?
- Select -
Yes
No
Aware of circumstances which could give rise to a claim?
- Select -
Yes
No
Anything to Declare under Duty of Disclosure?
- Select -
Yes
No
Additional Information about you or the property
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