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 DetailsOwner Occupied by Insured/Family(Required) Yes No Vacant/Unoccupied(Required) Yes No Insured is Tenant(Required) Yes No OtherIs this a holiday home(Required) Yes No If yes – How often do you reside at the property?Security 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 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?Cover Required(Required)Extra (Defined events) (Provides cover for listed events in the policy wording i.e. Fire, Storm, Impact, Lightning etc.) Elite (Accidental loss & damage) (Provides cover for the above plus any accidental loss or damage to building and contents) Extra Elite BuildingContentsSpecified Art/Jewellery/Valuables (inside the home)Specified Jewellery/Valuables (outside the home)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 policyDoes your property include a dam, below ground motors or pumps?(Required)(e.g. tank or ground water) Yes No Is your property on (or near) the waterfront (ocean, canal, river) - include a Jetty or Pontoon?(Required) Yes No Do you have a Pool/spa?(Required) Yes No Does your home include a glass enclosure such as conservatory/green house?(Required) Yes No Do you operate a business and/or store property of a business at home or do any farming?(Required) Yes No If yes, what type & activities (who visits the home)?Do you have any paying students, boarders or guests staying with you?(Required) Yes No Do you have any sporting interests, hobbies or collections:(Required) Yes No If yes, what type?Do you regularly travel overseas or Australia Wide?(Required) Yes No Do you want to cover your Contents/Valuables away from the home?(Required) Yes No Will the house ever be unoccupied?(Required) Yes No Do you require Flood Cover?(Required) Yes No This field is hidden when viewing the formFlood cover questionsIf yes, Have you previously experienced or are you aware of any flooding or drainage problems at your address?(Required) Yes No Have you suffered any loss or damage attributed to flood at your situation?(Required) Yes No Do you live in close proximity to a watercourse?(Required) Yes No Does the land on which your home is located have adequate drainage?(Required) Yes No This field is hidden when viewing the formFlood cover questions endDo you or your family members serve on the committee of any club or association?(Required) Yes No Do you open your home to any sort of exhibition?(Required)(e.g. Open Garden Program) Yes No Do you employ anyone to assist with domestic duties?(Required) Yes No If yes, you may require a domestic workers compensation policy to cover these Employees. Refer client to WorkCover Queensland for quote – Ph: 1300 362 128NameThis field is for validation purposes and should be left unchanged. Δ
