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

Brick/Concrete Other

 Construction of Floors

Concrete Other

 Construction of Roof

Brick/Concrete Iron/Tile Other

 Sprinkler System

 Hydrant/Hoses

 Extinguishers

 Security Alarm

No Alarm Local Monitored

 Fire Alarm

 Deadlocks on external doors

 Key locks &/or Bars on Windows

 Age of Building

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

Yes No

 Sandwich Paneling

No Yes

 INSURANCE – Details

Building

Rewriting of Records

Removal of Debris

Other

if other please provide details

Additional Increase Cost of Working

Annual Rent

Other

if other please provide details

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 $5,000,000 $10,000,000 $20,000,000 Property Owners Liability Only

 PREVIOUS INSURANCE - Details

  Have you ever suffered any losses or claims

No Yes

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

No Yes  

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

No Yes  

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

No Yes  

 CONTACT – Details

First Name*

Surname*

  Phone No

   (please include area code)

Email Address*

How did you find us?*
---Please Select--- American Vehicle Sales Better Buying Group Building Commission Building Industry Solutions Building Inspector Conveyancer Fair Trading Dept NSW Friend or Family Member Google Search Government Department Im a Existing CGIB Client Insurance Broker Insurance Company Internet Search Steadfast White Pages www.ownerbuilder.net.au Yellow Pages Book Yellow Pages Online Other if other, please provide details

 * 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.