Your Details

First Name *

Last Name

State *

Phone *

Email Address *

Are you currently insured? *

Yes No

Renewal Date *

Property Details

What type of cover are you looking for? *

Building OnlyContents OnlyBuilding and Contents

Building Type *

HouseTownhouseSemi-DetachedDuplexTerraceGranny FlatNursing Home UnitApartment

Where do you currently live? *

Street address *Street address line 2

City *

State *

Postcode *

Country

Is business conducted from home? *

YesNo

Occupancy Type *

Owner OccupiedRent/LeaseHoliday Home

How many storeys in the building? *

OneTwoThree or more

Sum Insured

What is your contents sum insured? ($) *

Do you require cover for any portable items outside the insured address? *

YesNo

How much do you need? ($)

Do you require additional cover for valuable items? *

YesNo

How much do you need? ($)

Security Details

Type of security on external doors *

NoneDead locks onlyKey card access onlyDead locks and key card access

Type of window security *

NoneBarsBars and window locksWindow locksNo accessible windows

Type of alarm *

NoneUnmonitored burglar alarmMonitored burglar alarm

Claims History

How many claims have you made in the last 3 years?

When did you make your most recent claim?

Have you been declined for Insurance? *

YesNo

Have you had a claim declined? *

YesNo

Have you had any criminal convictions of fraud or arson? *

YesNo

Policy Information

When would you like the policy to be effective from? *

Would you like to add this to an existing policy? *

YesNo

Payment Type *

AnnualInstalments

Date of birth of the oldest insured *

Comments / Additional Information

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