INSURED'S - Details

  Name of Insured/s*

  Location*

 City/Town*

Post Code*

  Postal Address*

 City/Town*

Post Code*

  Occupied By *

Please Select Builders Display Home Tenant/s Vacant Premises  

Date of Birth*

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 / Jan Feb March April May June July Aug Sept Oct Nov Dec / (Date of birth of oldest insured)

PREMISES - Details

 Construction of Walls

Brick/Concrete Other

 Building Type

Please Select Single Storey Home Multi Storey Home Town House Unit on Ground Level Unit Above Ground Level Security Unit Other

 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 plus years

 Connected to Town Water?

No Yes

 Is the home Heritage Listed?

No Yes

24 hr security person/concierge

 Size of the home? (sqm)

 Condition of Home?

Good Average Needs Repair

 Is the House:

Rewired Replumbed

 INSURANCE – Details

Building Sum Insured                   $

Contents Sum Insured                  $

Annual Rent                                $

Domestic Workers Compensation Cover

No Yes (Available in NSW, ACT, TAS and WA)

 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)

  Fax 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.