INSURED'S - Details

  Owners name*

  Property Address*

 City/Town*

Post Code*

  Postal Address*

 City/Town*

Post Code*

Tenants Occupation*

Annual Rent*

PREMISES - Details

 Construction of Walls

Please Select Brick/Concrete Other

 Construction of Floors

Please Select Concrete Other

 Construction of Roof

Please Select Brick/Concrete Iron/Tile Other

 Sprinkler System

 Hydrant/Hoses

 Extinguishers

 Security Alarm

Please Select No Alarm Local Monitored

 Fire Alarm

 Deadlocks on external doors

 Key locks &/or Bars on Windows

 Age of Building

Please Select 1 - 5 years 6 - 10 years 11 - 20 years 21 - 30 years 31 - 40 years 41 - 50 years 51 - 60 years 61 - 70 years 71 - 80 years 81 plus years

 Connected to Town Water

Please Select Yes No

 Sandwich Paneling

Please Select No Yes

 INSURANCE – Details

Building

Rewriting of Records

Removal of Debris

Other

Additional Increase Cost of Working

Annual Rent

Other

GLASS

Not Required Internal Only External Only Internal & External

TAX INVESTIGATION

Not Required $10,000 $20,000 $30,000 $40,000 $50,000

LIABILITY

Not Required Property Owners Public Liability Sum Insured $5,000,000 Property Owners Public Liability Sum Insured $10,000,000 Property Owners Public Liability Sum Insured $20,000,000

 PREVIOUS INSURANCE - Details - MUST COMPLETE ALL QUESTIONS

  If "YES", Please provide the date your existing policy expirers* Please Select 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Not Insured / Please Select Jan Feb March April May June July Aug Sept Oct Nov Dec Not Insured / Please Select 2009 2010 2011 2012 2013 2014 2015 2016 Not Insured

  Have you ever suffered any losses or claims?

Please Select No Yes - Provide Details Below

  Have you ever had any insurance cancelled or declined or special terms imposed?

Please Select No Yes - Provide Details Below  

  Have you ever been charged or convicted of any criminal offence or declared bankrupt?

Please Select No Yes - Provide Details Below  

  Are you aware of any matters not disclosed above that is relevant to the underwriter's consideration of this insurance?

Please Select No Yes - Provide Details Below  

 CONTACT – Details

First Name*

Surname*

  Fax No

Email Address*

*Mandatory Fields

Thanks for completing our online form.

We will endeavour to contact you with your insurance details soon.

Meanwhile, if you require any further assistance please feel free to contact us.

We may need to contact you to obtain additional information to provide you with an insurance quotation.

Completion of this form does not put an insurance policy/cover in place - you will need to contact us to arrange insurance cover.

All information you provide must be correct, true, and accurate as incorrect or misleading information may alter our quote and jeopardise cover if you proceed with a policy.

We recommend that you read the relevant Product Disclosure Statement when considering an insurance policy.