Home & Contents Quotation

Full Name *
Email *
Phone *
Date of birth Date of birth * / MM / DD YYYY
Address
Street Address *
Minimum of 5 characters required. Currently Entered: 0 characters.
City *
State *
Postal / Zip Code *
Start Date of Policy Start Date of Policy * / MM / DD YYYY
Current Insurer *
Cover Required *
How is the home occupied *
Approximate year built: *
If over 30 years has it been re-wired or re-plumbed? *

If over 30 years has it been re-wired or re-plumbed? Yes No
Type of home: *
What are the externals walls made from?
What is the construction of your roof? *
Is your home part of strata or body corporate? *

Is your home part of strata or body corporate? Yes No
Do you have a pool? *

Do you have a pool? Yes No
Is your property larger than 5 acres? *

Is your property larger than 5 acres? Yes No
Building Sum Insured? *
Contents Sum Insured? *
Personal Property / Valuables

(items that leave your home)
Item - Description

One per box
Item Description line 1
Sum Insured line 1
Item Description line 2
Sum Insured line 2
Item Description line 3
Sum Insured line 3
Item Description line 4
Sum Insured line 4
Item Description line 5
Sum Insured line 5

Security at your home *
Security at your home	Yes	No
Deadlocks on all external doors	Deadlocks on all external doorsYes	Deadlocks on all external doorsNo
Key Lockable Window locks	Key Lockable Window locksYes	Key Lockable Window locksNo
Security Bars / Grilles on Windows	Security Bars / Grilles on WindowsYes	Security Bars / Grilles on WindowsNo
Alarm	AlarmYes	AlarmNo

Alarm Type
Alarm Type	Yes	No
Local	LocalYes	LocalNo
Monitored (back to Base)	Monitored (back to Base)Yes	Monitored (back to Base)No

Claims
Claims	Yes	No
In the last five years you had any claims	In the last five years you had any claimsYes	In the last five years you had any claimsNo

During the past 5 years
During the past 5 years	Yes	No
Have you declared bankrupt	Have you declared bankruptYes	Have you declared bankruptNo
Have you been convicted of a criminal offence	Have you been convicted of a criminal offenceYes	Have you been convicted of a criminal offenceNo

if yes to either of the above questions, please give details:
Mortagee

Mortagee Yes No
if yes,who:
Acceptance Criteria

Is the property
- used for business purposes other than home office or surgery?
- under construction, reconstruction or renovation?
- in poor condition or poorly maintained?
- currently unoccupied or expected to be unoccupied for more than 90 continuous days during the period of cover?
- under any heritage listing/National Trust listing or order?
- used as a hostel, bed and breakfast or guesthouse?
- used for community housing or public housing?
Please insert additional information regarding the options you checked as "yes"
Any additional information: