Step 1 of 5 - Insured Details 20% Insured Name /Entity(Required)Person providing information(Required)Date of Birth for Oldest Insured(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Address to be insured(Required)Street AddressCityStatePostcodePostal AddressStreet AddressCityStatePostcodeContact Number(Required)Email address(Required) Policy Start DateDayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Current insurer & Current due date of policy Insurance, Financial & Social HistoryIn connection with this policy have you, your spouse, your partner or in the case of a company the Directors, either alone or conjointly through partnership or Directorships in other companies:-Ever had any insurance refused, cancelled, declined or had increased terms imposed?(Required) Yes No During the past 10 years, have you:Been declared Bankrupt or been a director of a company which became insolvent?(Required) Yes No Been charged or convicted of a criminal offence?(Required) Yes No In relation to this property:Are the premises occupied? If unoccupied, cover restrictions may applyAre there any hazards/defects occupied with the property?(Required) Yes No If yes, details requiredIs the building Heritage listed?(Required) Yes No If yes, details requiredDoes the building contain Asbestos? If yes, Asbestos report needed(Required) Yes No If yes, details requiredIs there a Mortgagee to be noted on the policy?(Required) Yes No If yes, details requiredDo you have plans to renovate this property?(Required) Yes No If yes, details requiredDuring the past 5 years, have you or any person to be insured under this policy:Ever had any insurance claims in the last 5 years?(Required) Yes No If yes to the above question, please provide additional information in table provided - or attach the last 5 years claims history from the underwriterDateDetails of Claim, Incident or Offence (include type of claim, incident or offence, penalty or fine, details of suspensions and restrictions, name insurer)Amount paid Attach the last 5 years claims history from the underwriter Drop files here or Select files Max. file size: 2 MB. About the PremisesHave you just purchased this property?(Required) Yes No If yes, what is the date of settlement(Required) DD slash MM slash YYYY Year BuiltIf older than 1980 is there any record of it being rewired and/or re-plumbedNumber of StoreysIs there any Pools(Required) Yes No How manyIs there any Elevator / Lift(Required) Yes No How manyIs there a Tennis Court(Required) Yes No Is there a pool(Required) Yes No Is there a Jetty / Wharf(Required) Yes No Is there a Pontoon / Marina(Required) Yes No Anything else to declareOccupancy DetailsIs the home currently Occupied(Required) Yes No Is the property used for holiday letting(Required) Yes No Vacant/Unoccupied(Required) Yes No OtherSecurity DetailsDouble keyed deadlocks on all External Doors(Required) Yes No Key locks on all accessible Windows(Required) Yes No Security Screens on Doors(Required) Yes No Security Screens/Bars/Grills on Windows(Required) Yes No Local Alarm(Required) Yes No Monitored (Back to Base) Alarm(Required) Yes No Safe(Required)Fixed Yes No Other About the TenancyIs there a current written rental agreement in place?(Required) Yes No If yes, what is the period/expiry date of the lease?DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Lease(Required) Single Lease Multi Leases What is the rental amount?per weekDo you have a managing agent looking after this property?(Required) Yes No If Yes who are they?Do you authorise us to provide information to them (i.e., COC, C/F’s, Info)?(Required) Yes No Is there a bond being held?(Required) Yes No If yes, what is the amountDoes your current tenant have a history of rent arrears or any current problem under the lease?(Required) Yes No If yes, please detailAre you aware if the tenant operates a business and/or stores property of a business at home?(Required) Yes No If yes detailsWill the house ever be unoccupied for more than 60 days?(Required) Yes No Do you require cover/quote for Loss of Rent (following damage e.g. fire, storm)?(Required) Yes No Do you require cover/quote for Rent Default?(Required) Yes No Do you require cover/quote for Malicious Damage by Tenants?(Required) Yes No Do you require cover/quote for Theft by Tenants?(Required) Yes No Do you require cover/quote for Accidental Damage?(Required) Yes No Construction DetailsExternal Walls Brick/Concrete Wood/timber Fibro/asbestos Other External Cladding(Required) Yes No Cladding name(i.e. Fibre Cement, Weatherboard/Timber, Blueboard, Weathertex/Fibre cement, Hardiplank/timber etc.NameLocationPercentages of cladding on the buildingDoes the building contain ACP/EPS/Cladding?(Required) Yes No If yes detailsWhat %Product nameFloor(Required) Concrete Wood Roof Concrete Metal/Iron Concrete or terracotta Tile Slate Fibro Are there any building defects or outstanding maintenance items that we should be aware of?BuildingLandlord fixtures & Fittings / ContentsRental income per weekRent Default/Theft by TenantsMalicious Damage(Required) Yes No Liability(Required) $10,000,000 $20,000,000 Machinery BreakdownIs cover for Flood required?(Required)The definition of flood is: the covering of normally dry land by water that has escaped or been released from the normal con-fines of: any lake, or any river, creek or other natural watercourse, whether or not altered or modified; or any reservoir, canal, or dam. Yes No Additional informationIs there a mortgagee to be listed on this policy?(Required) Yes No If yes please advise the entity that you require notingWhat is the size of your land?If over 2 HA - will need to be on farm policyDam, below ground motors or pumps(Required)(e.g. tank or ground water) Yes No Pool/spa(Required) Yes No Town water connected(Required) Yes No Glass enclosure such as conservatory/green house(Required) Yes No Jetty/Pontoon(Required) Yes No Do you have plans to renovate this house (costs over $50,000)?(Required) Yes No Is the property on (or near) the waterfront (ocean, canal, river)?(Required) Yes No Have you previously experienced or are you aware of any flooding or drainage problems at your address?(Required) Yes No Does the land on which your home is located have adequate drainage?(Required) Yes No Do you keep any of your personal property at the house / unit (e.g. cloth-ing, bicycles, surfboards):(Required) Yes No Do you employ anyone to assist with domestic duties?(Required) Yes No NameThis field is for validation purposes and should be left unchanged. 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