Name:

Phone (Home):

Phone (Work):

Email Address:

Have you ever had insurance cancelled
or refused?

Do you currently insure your property?

Number of years prior insurance:

Expiry date with present Insurer
(dd/mm/yyyy)

What is your date of birth? (dd/mm/yyyy)

Property type:

Use:

Year built:

Is property equipped with a alarm?

Are you within 300 m of a hydrant?

Are you within 13 km of a firehall?

Amount of coverage required - ( Most homes have to be ensured for replacement value. A detailed calculation will need to be done. As a rough guide assume 220 per sq. ft. )

Contents:

Liability:

Deductible:

Recent claims:

Type:

Date (mm/yyyy)

Location involved:

#1:

#2:

#3:

Comments: