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Home Insurance Form
Insurer's Details
Property Details
Security Details
Sums Insured
Claims
General
Insured’s First Name
Insured’s Last Name
Insured's Phone Number
Insured's Email Address
Date of Birth
Property Address
Occupancy Type of Home
-- Select an answer --
Owner occupied
Rent/Lease
Holiday home
Has the insured in the last 3 years had any of the following:
-- Select an answer --
Been declined insurance
Had a claim declined
Had any criminal convictions for fraud or arson
Please provide further details:
Would you answer yes to any of the following:
-- Select an answer --
Will the property ever be unoccupied for more than 100 continuous days?
Is the home under construction/renovation?
Is the property poorly maintained or in poor condition?
Is the property heritage listed? If yes, please provide details and Heritage Register Listing number
Please provide further details:
Construction style
-- Select an answer --
Modern project home (1960 to present)
Modern architect design (1960 to present)
Post War (1946-1959)
War (1914-1945)
Federation (1891 – 1913)
Victorian (1840-1890)
Has the property been re-wired or re-plumbed within the last 50 years ?
Yes
No
Original year built
Construction type
-- Select an answer --
AAC panel
Blockwork
Brick veneer
Double brick
Panel wall system
Stonework
Stonework veneer
Weatherboard
Weatherboard – artificial
Other
Roof type
-- Select an answer --
Concrete tile
Fibre cement covering
Metal covering
Slate
Terracotta
Timber shingles
Other
Construction quality of the home
-- Select an answer --
Standard
Quality
Prestige
Original year built
Storeys
Do you have a swimming pool or built in outdoor spa on the property?
Yes
No
Windows security
-- Select an answer --
Key operated locks
Security screens or bars
No accessible windows
None of the above
Door security
-- Select an answer --
Key operated dead locks/bolts
Security cards
None of the above
Is the property alarmed?
Yes
No
If yes, which type
Monitored
Local
Building sum insured
$
Contents sum insured
$
Do you want to specify any valuable items? (i.e. cover them above the limits in the policy)
Yes
No
If yes to the above, please provide description and amount to be insured:
Has there been any claims in the last 3 years?
Yes
No
If yes, type of claim and year of claim
Is business conducted from the home?
Yes
No
If yes, would you like the home business extension?
Yes
No
Who is your current insurer?
Interested parties?
Email address
